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A 9-year-old girl was referred by her pediatrician to a child neurologist for headaches.  The child neurologist first saw the patient on 9/10/2009. The patient’s mother stated that the patient’s headaches started in 7/20/2009.  The patient had no episodes of loss of consciousness of any type. The child neurologist’s review of systems revealed headaches, neck pain, and back pain.  The child neurologist noted headaches following a viral infection in July 2009 described as constant tension and pressure with nausea, photophobia, and difficulty concentration.  The child neurologist’s diagnosis was childhood migraine and prescribed 10 mg amitriptyline. The child neurologist ordered an MRI to rule out neoplasm and aneurysms. The child neurologist also ordered an EEG, which was not indicated for headaches.

On 9/18/2009, the EEG was performed.  The technician described the EEG with “sharp and slow waves.” On 9/30/2009, the child neurologist saw the patient for an office visit.  The child neurologist read the EEG as showing “generalized polyspike and wave which was synchronous bilaterally over both hemispheres which is highly suggestive of a generalized seizure disorder.”  The child neurologist stopped the amitriptyline 10 mg she prescribed at the last visit because of “seizures on EEG.” She ordered a neurosurgery consult and planned a separate meeting with the mother.

The child neurologist next saw the patient on 11/4/2009.  The child neurologist prescribed Depakote at 250 b.i.d. The patient’s Depakote level was at 72.  The patient reported no seizures or auras, but the child neurologist in her diagnosis documented “seizures, breakthrough.”  The child neurologist ordered a second video EEG with computer analysis without medical indication. The EEG was performed on 11/25/2009.  The technician report showed no abnormality. The child neurologist’s report was of generalized polyspike and slow waves bilaterally, “highly suggestive of generalized epilepsy,” with localized slowing in the left temporal area.

On 2/11/2010, the child neurologist saw the patient for a follow-up visit.  The chief complaint was learning difficulty. The Depakote level was 53. The patient denied experiencing any auras and/or any seizures.  On the next visit, on 5/11/2010, the patient still did not report any auras or seizures. The child neurologist’s diagnoses were generalized epilepsy, childhood headaches, adverse effect of medication, and learning disability.  The child neurologist ordered a third video EEG with computer analysis to rule out seizures and BAER (brainstem auditory evoked response) to rule out hearing loss, despite no medical indication. The video EEG was performed on 6/28/2010 and was normal.  On 7/12/2010, the child neurologist saw the patient for a follow-up visit. The patient denied having headaches and seizures. The child neurologist ordered a 72-hour ambulatory EEG despite the normal EEG.

The child neurologist next saw the patient on 1/19/2011 for a follow-up visit.  The patient’s mother complained that the patient’s math and history test results were still low.  The patient had no witnessed seizures and was tolerating Keppra well. Despite the negative findings, the child neurologist diagnosed “seizures, breakthrough, rule out.”  The child neurologist ordered another video EEG. At this point in time, the 72-hour video EEG she previous ordered on 7/12/2010 had not been performed.

On 2/18/2011, a 72-hour ambulatory EEG was performed.  The child neurologist’s last visit with the patient was on 3/14/2011.  On the last visit, the child neurologist noted that the 72-hour ambulatory EEG was normal.  She discontinued Keppra. She diagnosed the patient with “arachnoid cyst, middle cranial fossa; generalized epilepsy; learning disability; and adverse effect of medication given correctly.”

The Medical Board of California judged that the child neurologist’s conduct departed from the standard of care because she ordered 3 video EEGs and an ambulatory EEG without medical indication, ordered a BAER with no medical indication, misdiagnosed epilepsy on a patient with no medical history of seizures of any type, and made diagnoses of breaththrough seizures with no basis, contrary to her own findings that were no auras or seizures reported.

The Medical Board of California placed the child neurologist on probation and ordered the child 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 child neurologist was assigned a practice monitor and was prohibited from supervising physician assistants and advanced practice nurses.

State: California

Date: January 2018

Specialty: Neurology, Pediatrics

Symptom: Headache, Nausea Or Vomiting, Back Pain, Head/Neck Pain

Diagnosis: N/A

Medical Error: Unnecessary or excessive diagnostic tests, False positive

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

A 14-year-old girl was referred by her pediatrician to a child neurologist for seizures.  The child neurologist first saw the patient on 8/10/2009. The patient’s first seizure occurred at age 10, early morning on 2/21/2006, and a second episode occurred in the early morning sometimes around December 2008.  At the time the patient saw the child neurologist, her medication included Klonopin 0.5 mg p.m., Depakote at 750 b.i.d., and Vistaril 10 mg p.m. The patient’s MRI on October 2008 was normal. The patient’s EEG performed on October 2007 noted 3-13 seizures.  The child neurologist’s assessment was “juvenile myoclonic epilepsy; rule out adverse effect of med correctly given; insomnia unspecified; depressive disorder; and cafe au lait spots x 2.” The child neurologist ordered a video EEG “to rule out any epileptogenic foci.”

On 8/12/2009, the video EEG was performed.  The technician reported sharp and slow waves left F3-C3.  The child neurologist read it as normal. A BAER was performed on the same day even though it was not ordered by the child neurologist.  The BAER was not indicated, and the referring diagnosis for the BAER was not in the record and was used only for billing.

The child neurologist next saw the patient on 8/21/2009 for a follow-up visit.  The child neurologist noted that the patient was tolerating Depakote well. The Depakote level was 101.  The child neurologist diagnosed breakthrough seizures despite the fact that no seizures were reported. The child neurologist added Topamax Sprinkles 25 mg to increase to 50 mg b.i.d.  She stopped the Klonopin and Vistaril.

On 11/2/2009, the child neurologist saw the patient for a follow-up visit.  She noted that patient was gaining weight with Topamax and wanted to stop Depakote, though it was well tolerated.  The patient had no seizures and no myoclonic jerks. The child neurologist ordered another video EEG without medical indication.  The result of the second video EEG was normal. The child neurologist’s reading of the video EEG followed a template and was the same with all of her video EG reports except for the first paragraph regarding time of sleep, wake, and meals.

The child neurologist next saw the patient on 5/3/2010.  The patient reported no auras or seizures. The child neurologist noted under past medical history that the patient had suicidal thoughts.  The child neurologist did not address this issue during this visit. The child neurologist continued Topamax 50 mg b.i.d., even though there was a note of memory problems.  The child neurologist reduced Depakote to 500 b.i.d. She ordered labs and a 4-day ambulatory EEG without any medical indication. The 2 previous video EEGs were normal, and the patient did not have any seizures.  The patient underwent a third video EEG on this visit, which was not ordered nor medically indicated.

On 6/8/2010, the child neurologist saw the patient for a follow-up visit.  The patient was taken off Topamax. Her memory improved, but her headaches recurred.  The child neurologist diagnosed migraines without asking sufficient questions to make that diagnosis.  She added amitriptyline 10 mg, Imitrex 100 mg, and continued Depakote 500 b.i.d.

The 4-day ambulatory EEG ordered on 5/3/2010 was performed on 7/6/2010.  It was completed despite the fact that the patient just underwent a third video EEG on 5/3/2010.  There was no medical indication for the 3 previous EEGs and the 4-day ambulatory EEG. The 4-day ambulatory EEG was read as normal.

On 8/23/2010, the child neurologist saw the patient for 2 back-to-back seizures that occurred on 8/11/2010.  The patient was taken to the emergency room with a history of early morning twitching since the seizures. The child neurologist’s assessment was breakthrough seizures.  The child neurologist added Lamictal 100 mg b.i.d. and raised Depakote from 500 mg b.i.d. to 1000 mg b.i.d. The child neurologist failed to recognize that on 7/29/2010, the patient was having myoclonic jerks, which were described as twitches.  The patient had been on 750 mg b.i.d. with a level of 100 and had been seizure free for 2 years. The child neurologist failed to recognize the important interaction between Lamictal and Depakote. The child neurologist failed to consider that it was very likely that the patient had toxic levels of both Depakote and Lamictal.  The child neurologist did not check the patient’s blood levels. The child neurologist ordered another video EEG and another ambulatory EEG. The video EEG was performed on September 2010 and was normal. The child neurologist used the same template on her report.

The child neurologist next saw the patient on 11/4/2010.  The patient was unable to sleep, had difficulties with coordination and balance, was forgetful; all symptoms consistent with medication toxicity.  The child neurologist failed to recognize it as such. The patient was on Depakote 500 mg b.i.d. and Lamictal 100 mg b.i.d. Suicidal ideation was noted in the child neurologist’s previous notes, but the child neurologist failed to address this issue.  The child neurologist added Prozac 20 mg, which had a black box warning for suicidal ideation.

The Medical Board of California judged that the child neurologist’s conduct departed from the standard of care because she ordered 4-5 video EEGs and an ambulatory EEG without medical indication, ordered a BAER with no medical indication, lacked knowledge and/or did not consider the important interaction between Depakote and Lamictal.  The child neurologist diagnosed migraines without establishing diagnostic criteria, diagnosed circadian sleep disorder without asking any questions regarding symptoms and adding the polysomnogram report in the chart, and prescribed Prozac to patient with a history of suicidal thoughts despite the black box warning.

For this case and others, the Medical Board of California placed the child neurologist on probation and ordered the child 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 child neurologist was assigned a practice monitor and was prohibited from supervising physician assistants and advanced practice nurses.

State: California

Date: January 2018

Specialty: Neurology, Pediatrics

Symptom: Headache

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

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

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

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 2/17/2014, a male patient in his early twenties presented to a family practitioner for medical assessment and/or treatment.

On 2/17/2014, the patient disclosed to the family practitioner that he was obtaining injectable testosterone from a source unknown to the family practitioner.  The patient indicated that he was utilizing the testosterone for bodybuilding purposes.

On 2/17/2014, the patient reported to the family practitioner that he was suffering from headaches and elevated blood pressure.

On 2/17/2014, the family practitioner surmised that the patient’s symptoms were likely the result of excess estrogen production secondary to the patient’s high-dose testosterone use.

On 2/17/2014, the family practitioner wrote the patient a prescription for Anastrozole, an estrogen-blocking substance.

On 2/20/2014, the patient presented to the family practitioner for medical assessment and/or treatment.  The family practitioner continued the patient on Anastrozole.

In February 2014, the family practitioner did not obtain or review any medical records establishing that the patient was experiencing excess estrogen production.  He also did not obtain bloodwork or perform other diagnostic testing to confirm whether the patient was experiencing excess estrogen production.

On 4/6/2014, the patient presented to the family practitioner for medical assessment and/or treatment.  The patient reported to the family practitioner that he was continuing to use testosterone, and that he was continuing to experience headaches.  The family practitioner surmised that the patient’s ongoing headaches were caused by elevated prolactin levels.  The family practitioner wrote the patient a prescription for Cabergoline, a prolactin-blocking substance.

On 4/10/2014, the patient presented to the family practitioner for medical assessment and/or treatment.  The family practitioner continued the patient on Cabergoline.

In April 2014, the family practitioner did not obtain or review any medical records establishing that the patient was experiencing elevated prolactin levels.  He did not obtain bloodwork or perform other diagnostic testing to confirm whether the patient was experiencing elevated prolactin levels.

On one or more occasions between 6/27/2014, and 1/9/2015, the family practitioner prescribed the following substances to the patient: clindamycin, Bactroban ointment, doxycycline, Zithromax, oral prednisone, Neurontin, and diazepam.  On one or more occasions in 2015, the family practitioner also prescribed the patient Anastrozole.

The family practitioner did not keep any contemporaneous medical records regarding the medical assessment and/or treatment that he provided to the patient between 2/17/2014 and 1/9/2015.

To the extent that the family practitioner had medical records regarding the medical assessment and/or treatment that he provided to the patient between 2/17/2014 to 1/9/2015, such records were all created in October 2015.

The Medical Board of Florida issued a letter of concern against the family practitioner’s license.  The Medical Board of Florida ordered that the family practitioner pay a fine of $8,000 and pay reimbursement costs for the case at a minimum of $1,457.57 and not to exceed $3,457.57.  The Medical Board of Florida ordered that the family practitioner complete a drug course, a medical records course, and five hours of continuing medical education in “risk management.”

State: Florida

Date: December 2017

Specialty: Family Medicine, Endocrinology, Internal Medicine

Symptom: Headache

Diagnosis: Drug Overdose, Side Effects, or Withdrawal

Medical Error: Failure to order appropriate diagnostic test, Improper medication management, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

On 11/7/2011, a patient presented as a “medical emergency” and was seen by a physician assistant at a correctional facility.  The patient was a 62-year-old man whose medical record included a history of arthritis, diabetes, and hypertension for which he was treated with blood pressure medication.

The patient told the physician assistant he thought he had a stroke three days earlier and described symptoms of chest pain, left-sided tingling, left-sided weakness, headache, and loss of vision in the bottom visual field of his left eye.  The patient’s presenting blood pressure was 180/94 with a repeat at the end of the visit of 127/82.  The physician assistant noted normal pupil, funduscopic, heart and lung exams.  Cranial nerves II-XII were intact.  The patient’s strength was equal bilaterally.  An EKG was done and interpreted as having a normal sinus rhythm.  The physician assistant’s diagnosis was “No evidence of stroke.”  The patient was given a GI cocktail and released to his unit.

The physician assistant did not verify the patient’s complaint by conducting a visual field exam.  The physician assistant did not consider temporal arteritis as a possible cause of the patient’s vision loss.  Also, he did not at that time discuss his care of the patient with a supervising physician.  The physician assistant failed to recognize the emergent nature of the complaint of sudden vision loss by a patient.

The patient again presented to the physician assistant a week later on 11/14/2011.  He reported continued loss of vision in the bottom visual field of his left eye. The physician assistant completed a form recommending the patient be referred to an ophthalmologist.

The patient was seen two weeks later on 11/29/2011 by a local ophthalmologist who ordered a sed rate to help rule out temporal arteritis and placed the patient on clopidogrel.  The ophthalmologist diagnosed “[a]cute anterior ischemic optic neuropathy OS.”  He stated that at the visit the patient was “already showing signs of superior optic atrophy and inferior visual field loss from superior involvement approximately three weeks previous.”

The Commission stipulated the physician assistant reimburse costs to the Commission and write and submit a paper, with bibliography, on the evaluation of a patient with non-traumatic sudden vision loss.

State: Washington

Date: August 2017

Specialty: Physician Assistant, Family Medicine, Internal Medicine

Symptom: Vision Problems, Headache, Chest Pain, Weakness/Fatigue

Diagnosis: Ocular Disease

Medical Error: Diagnostic error

Significant Outcome: N/A

Case Rating: 5

Link to Original Case File: Download PDF

The Board was notified of a professional liability payment paid on 3/8/16.

A 48-year-old female presented to the emergency department three times over the course of two days with complaints of severe headache.

During the 7/28/12 visit, she had a non-contrast CT head, which was reported as normal.  The patient’s headache was treated as an acute migraine attack.  She was discharged with anti-migraine, anti-nausea, and anti-anxiety medications.

On 7/29/12, the patient returned with persistent symptoms, was treated symptomatically, and discharged.  Later that day, the patient again returned to the emergency department with continuing headache and persistent nausea and vomiting.

The patient was admitted to the hospital under the care of an internist.  The patient was started on maintenance IV fluids to treat dehydration and was treated for the underlying migraine with analgesics and antiemetic.

During the internist’s care of the patient, the internist did not order a spinal tap or additional CT scan, instead relying on the 7/28/12 emergency department CT scan.

On hospitalization day three, the patient was discharged with anti-migraine and anti-nausea medications, and was advised to follow up with her primary care physician or neurologist within a week.

On 8/2/12, the day after discharge, the patient returned to the emergency department with a continuing headache and a CT scan of her head showed intracranial hemorrhage in the right temporal lobe.

The patient was then airlifted to a tertiary care center and had clipping of a brain aneurysm/hematoma removal and ventriculoperitoneal shunt placement.

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 provide adequate care for severe persistent headache with normal neurological exam.  The medical expert found that the internist failed to perform a lumbar puncture and repeat imaging or seek neurology input.

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: July 2017

Specialty: Internal Medicine, Hospitalist

Symptom: Headache, Nausea Or Vomiting

Diagnosis: Intracranial Hemorrhage

Medical Error: False negative, Delay in proper treatment, Failure to order appropriate diagnostic test, Underestimation of likelihood or severity

Significant Outcome: Permanent Loss Of Functional Status Or Organ, Hospital Bounce Back

Case Rating: 4

Link to Original Case File: Download PDF

On 1/24/2014, a patient presented to an internist with symptoms of intractable migraine headaches.  The internist proceeded to test cortisol levels in the patient.

The Board judged the internists conduct to be below the minimal standard of competence given that he failed to use the proper lab data for diagnosing Addison’s disease or any related conditions, treat the patient with a standard dosage treatment of prednisone to start with, and utilize a taper of the prednisone dosage within a few days of starting.

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

State: Florida

Date: June 2017

Specialty: Internal Medicine, Endocrinology

Symptom: Headache

Diagnosis: Endocrine Disease

Medical Error: Failure to order appropriate diagnostic test, Improper medication management

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF

On 2/28/2012, a 27-year-old male presented to a neurologist with chief complaints of neck, lower back, and headache following a motor vehicle accident that occurred approximately 3 weeks earlier.  The patient denied any loss of consciousness in the accident and gave no history of suffering a head trauma. The patient’s neurological examination was normal except for mild reflex asymmetry in the upper and lower extremities and a slow gait.  The neurologist noted moderate tenderness on palpation of the cervical paraspinal musculature with full range of motion, but no neck stiffness. The neurologist listed his diagnoses of the patient as: post-concussive headache/migraine syndrome; status post MVA and head injury; cervical spasm; lumbar spasm; and the neurologist wanted to rule out cervical and lumbar radiculopathy.

On this initial visit, the neurologist performed an in-office EEG for the patient’s headaches and “head injury,” but the patient never reported suffering a head injury in the accident, or any loss of consciousness or any seizure activity that would justify this study at this time.  The EEG was normal. The neurologist also performed an in-office EMG and NCV of both bilateral upper and lower extremities, testing 68 muscles, which the neurologist stated took approximately 1 hour. During the study, the neurologist obtained no response of bilateral tibial H-Reflexes.  The neurologist’s impression of the NCV was that the patient suffered from “right sided mild carpal tunnel syndrome” in the “bilateral upper extremities.” The test results, however, did not support the neurologist’s impression as the patient did not have the electrophysiological features for carpal tunnel syndrome.  The neurologist’s further impression was that the patient “possible S1 radiculopathy,” however, the test results did not establish a diagnosis of S1 radiculopathy.

The neurologist also ordered an MRI of the patient’s brain, cervical spine, and lumbar spine.  The neurologist also advised the patient to obtain physical therapy/occupational therapy or chiropractic treatment, but the neurologist failed to write a prescription for physical or occupational therapy and failed to refer the patient to a facility where he could obtain such treatments.

On this visit, the neurologist billed $550 for the office visit, $4,320 for the NCV, $380 for he H-Reflex amp study, $640 for the needle EMG, and $1,125 for the EEG, for a total single visit charge of $7,015.

On 3/6/2012, the patient returned for a follow-up visit complaining of increased neck, shoulder, and low back pain.  The neurologist’s list of diagnoses remained the same as the previous visit and appeared to be cut and pasted into the new chart note.  During this visit, the neurologist performed “Cervical and Lumbar trigger points” injections, but there was no report documenting this procedure in the certified chart, and the neurologist’s billing summary did not reflect a charge for this procedure on this date.

On 4/19/2012, the patient underwent an MRI of his brain and lumbar spine at an outside facility, which were interpreted as normal.  The cervical MRI, however, revealed a 3 to 4 mm left paramedian disc protrusion at C7-T1, degenerative changes at C2 to C6, and a 13 mm x 6 mm lesion in the left lobe of the thyroid gland consistent with thyroid adenoma or colloid cyst.

On 4/30/2012, the patient returned for a follow-up visit complaining of neck and shoulder pain.  The neurologist noted moderate tenderness on palpation of the cervical paraspinal musculature at C6 to C7, but the patient’s range of movement was within normal limits.  The neurologist’s diagnoses were post-concussive headache syndrome, status post MVA, and cervical and lumbar spasm.

The neurologist performed “Cervical Trigger point” injections at 6 different points, but there was no report documenting this procedure in the certified chart.  The neurologist also had the patient undergo an in-office carotid artery duplex scan even though the patient had no carotid bruits on examination, had no clinical evidence or history of vascular pathology involving the anterior circulation, nor any evidence or history of transient ischemic attack or other similar medical conditions, which would justify the scan.  The scan was completely normals. The neurologist charted that he asked the patient to go to “intense physical therapy” and told the patient that his symptoms were mostly due to spasm due to “cervical acute disc herniation.” The patient, however, did not have a herniated cervical disc.

On this visit, the neurologist billed $1,350 for the in-office carotid artery duplex scan, $950 for the trigger point injections with ultrasound guidance (for which there was no procedure report), $415 for interpreting the outside MRI of the spinal canal, and $415 for interpreting the MRI of the brain, which had been reported by the outside facility to be normal.

On 5/2/2012, the patient returned for another follow-up visit complaining of pain with spasm in his neck and shoulder area.  The neurologist charted that the patient stated the injections from 2 days earlier and the new medication helped relieve his pain, but it returned last night.  The neurologist noted neck pain and spasm in the midscapular area with “back pain/spasm but less.” The neurologist, however, did not explain how the patient’s back pain was less since on the prior visit, 2 days earlier, the patient had no back complaints.  The neurologist’s list of diagnoses were identical to those listed on the patient’s initial visit on 2/28/2012, including the status post “head injury” and ruling out “cervical and lumbar Radiculopathy,” which appeared to be copied and pasted from the February note.

On 5/18/2012, the patient returned for another follow-up visit complaining of severe neck pain.  The neurologist noted moderate tenderness in the cervical paraspinal muscles at C4 to C7, and moderate tenderness in the paraspinal muscles at L2 to S1, but the patient had no back complaints on this visit.  The neurologist’s list of “current” diagnoses were identical to those listed on the patient’s initial visit on 2/28/2012, including the status post “head injury,” “lumbar spasm,” and ruling out of “lumbar Radiculopathy,” which appeared to be cut and pasted from the initial visit in February.  In his unsigned cervical injection procedure report, the neurologist listed the patient’s diagnoses as cervical radiculopathy, cervical spinal stenosis, intractable migraine, post concussion headache, and cervical muscle spasm, but here was no evidence in the certified chart that the patient suffered from all these conditions.

On 5/30/2012, the patient returned for a further follow-up visit complaining of neck pain radiating into his left shoulder.  The neurologist’s review of systems was identical to that of the previous visit, including the misspelling, and appeared to have been copied and pasted from the prior note.  The neurologist noted back pain and spasms even though the patient had no back complaints on this visit and no tenderness was found upon examination.

The neurologist performed another NCV/EMG of the patient’s bilateral upper extremities, but there had been no significant change in the patient’s condition to justify repeating this test.  The neurologist’s impression was that the patient had bilateral cervical radiculopathy at C5-C7, inter alia, but the test results did not support the neurologist’s impression for radiculopathy.

For all the previous appointments, the neurologist’s plan was to order physical therapy for the patient, but there as no prescription or order found in the certified chart indicating that the neurologist ordered or prescribed physical therapy on this visit.

On 6/13/2012, the patient returned for another follow-up visit complaining of increased neck pain radiating into his left shoulder.  The neurologist’s review of systems was identical to the previous visit, including the misspelling, and noted back pain and spasms even though the patient had no back complaints on this visit.  In his unsigned procedure note, the neurologist performed a cervical thoracic facet steroid injection, under ultrasound guidance, but the corresponding ultrasound images listed a date of 6/14/2012.  The consent for the procedure was not signed by the patient, and there was no explanation in the certified chart indicating why someone else signed the consent for the patient, who was alert and talking with the neurologist during the visit.  On this visit, the neurologist wrote a prescription for the patient to receive physical or occupational therapy.

On 6/27/2012, the patient returned for another follow-up visit with improved neck pain, but now complained of back pain and spasm.  The neurologist’s review of systems was identical to the previous visit, including the misspelling, and it appeared to have been copied and pasted from the prior note.  The neurologist noted moderate tenderness in the paraspinal musculature at L2-S1, but the patient’s range of motion was normal. The neurologist also recorded ankle jerks upon examination.  The neurologist performed another NCV/EMG of the patient’s bilateral extremities, which the neurologist interpreted as showing bilateral radiculopathy at L5 and S1, but the test results did not support a diagnosis of radiculopathy.  The neurologist again obtained no responses of the bilateral tibial II-Reflexes, demonstrating improper placement of the electrodes or that these areas were not tested.

Throughout these appointments, the neurologist failed to order additional tests or studies concerning the thyroid lesion identified on the cervical MRI, and failed to refer the patient to an endocrinologist or other appropriate specialist for further evaluation and treatment of the thyroid lesion.

The patient ordered a repeat MRI of the patient’s lumbar spine and continued physical therapy, but there was no documentation in the certified chart that the patient was actually receiving physical therapy at this time.  This appeared to be the last time the patient saw the neurologist, but there was a LabCorp lab request form in the certified chart indicating that labs were collected on 6/13/2014 at 3:48 p.m., but there was no corresponding chart notes reflecting a patient visit on this date

The Medical Board of California judged that the neurologist’s conduct departed from the standard of care because he failed to accurately analyze and interpret the repeat in-office EMG/NCV studies performed, appropriately evaluate the large lesion identified on the cervical MRI and/or refer the patient to an endocrinologist or other appropriate professional for its evaluation and treatment, fully evaluate and initially treat the patient’s neck and back pain and headaches with conservative care and non-interventional treatment, initially order physical therapy for the patient while repeatedly performing invasive treatments, and overall fully, properly, and appropriately evaluate and treat the patient’s complaints.

For this case and others, the Medical Board of California revoked the neurologist’s license.

State: California

Date: June 2017

Specialty: Neurology

Symptom: Head/Neck Pain, Headache, Back Pain, Joint Pain

Diagnosis: Spinal Injury Or Disorder

Medical Error: Unnecessary or excessive diagnostic tests, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, False positive, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

On 12/16/2011, a 44-year-old female first presented to a neurologist with a chief complaint of headaches on the left side of her head only and rated her pain as a 4 out of 10.  The neurologist noted moderate tenderness in the paraspinal musculature of the cervical spine at C4-C7 with some limited range of motion, but the neurologist failed to specify how, and in what manner, the patient’s range was limited.

The neurologist ordered an MRI of the patient’s brain and cervical spine and performed an in-office NCV/EMG of the patient’s bilateral upper extremities.  The neurologist’s impression was that the patient had moderate radiculopathy at C5 and C6 of the left, mild radiculopathy on the right, and mild carpal tunnel syndrome on the right.  The test results, however, did not support the neurologist’s impressions of radiculopathy or carpal tunnel syndrome. Also, the patient had no clinical examination findings for radiculopathy, making the need for this test, along with its findings, questionable.  The neurologist also misinterpreted the normal findings of the median motor and sensory distal latency and amplitude responses in diagnosing carpal tunnel syndrome.

The neurologist billed $350 for the office visit, $2,160 for the NCV, $380 for the H-Reflex amp study, and $50 for venipuncture, a charge which was not supported by the certified records, for a total charge for this single visit of $2,940.

On 1/11/2012, the patient had the MRI of her brain performed and interpreted by an outside facility, which showed no significant abnormalities or evidence of acute disease.  On 1/16/2012, the patient returned for a follow-up visit and complained of continued headaches, now a 7 out of 10, and stated they were worse at night, and she was unable to lay on her left side.  The neurologist noted moderate tenderness of the cervical paraspinal musculature at C4-C7 with limited range of motion bilaterally. The neurologist performed an occipital block and cervical trigger point injection under ultrasound guidance, but there was no report documenting this procedure in the patient’s certified chart.

The neurologist billed $450 for the office visit, $1,250 for the trigger point and nerve injection using ultrasound guidance (for which there was no procedure report), $415 to interpret the essentially normal MRI scan of the patient’s brain performed and interpreted by the outside facility, and $50 for xylocaine, for a total billing of $2,165.  This appeared to be the patient’s last visit with the neurologist.

The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because he failed to accurately analyze and interpret the NCV/EMG, provide appropriate evaluation and treatment of the patient’s headaches, and refer the patient to physical therapy.  The neurologist also billed for a venipuncture that was not performed or supported by the chart, an H-Reflex study, which was either not obtained or performed, and interpreting an essentially normal MRI of the patient’s brain performed, which was interpreted by an outside facility as showing no significant abnormalities or evidence of acute disease.

For this case and others, the Medical Board of California revoked the neurologist’s license.

State: California

Date: June 2017

Specialty: Neurology

Symptom: Headache

Diagnosis: N/A

Medical Error: Failure to examine or evaluate patient properly, False positive, Referral failure to hospital or specialist, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

The Board was notified of a professional liability payment made on 1/28/2016.

A 10-year-old presented to a physician assistant with a chief complaint of cough, headache, sore throat, and fever.  The patient’s blood pressure was elevated, 140/190, and she had a fever of 103.2 degrees F.  According to the history, the patient denied nausea, vomiting, or diarrhea.  In the physical examination, it was documented a normal respiratory assessment.  The patient was diagnosed with strep throat, prescribed amoxicillin, and the patient was discharged home.

The patient died two days later from pneumonia secondary to influenza infection, which was not listed in the differential diagnosis.

The Board expressed concern that the physician assistant did not consider influenza in the differential diagnosis, prescribed an antibiotic without identifying the pathogen responsible for the infection, and did not perform a blood pressure recheck for the patient’s hypertension.  The Board noted a failure to document providing adequate follow up instructions to the patient’s family enumerating red flag signs and symptoms which would prompt the family to return the child to a health care facility.

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: April 2017

Specialty: Physician Assistant, Emergency Medicine, Pediatrics

Symptom: Fever, Cough, Headache

Diagnosis: Pneumonia

Medical Error: Diagnostic error, Lack of proper documentation

Significant Outcome: Death

Case Rating: 3

Link to Original Case File: Download PDF