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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 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 11/15/2013, a patient complained of chest pain radiating to his neck, throat, and across his back.  The patient stated the onset of the pain was noted to be one hour prior to his arrival at the hospital while he was screwing something into the wall, and that the pain was exacerbated by movement.

An ED physician performed an initial EKG, labs, and a chest x-ray on the patient.

The ED physician initially treated the patient with nitroglycerin and a GI cocktail, and subsequently with diazepam, morphine, Toradol, and Dilaudid.

The ED physician’s final assessment of the patient noted that the patient was still complaining of left side neck pain and “trap pain.”

The ED physician discharged the patient with a diagnosis of “musculoskeletal chest pain” and prescribed naproxen, Norco, and diazepam, along with instructions to follow up with him in three to five days.

The patient returned to the hospital the following day in cardiac arrest and expired on 11/16/2013.

The Medical Board of Florida judged the ED physician’s conduct to be below the minimal standard of competence given that he failed to perform a CT of the patient’s chest to evaluate for aortic dissection.  He also failed to adequately document bilateral pulses and/or blood pressures in the patient.  He failed to pursue other etiologies of the patient’s reported pain.  The ED physician failed to admit the patient for further observation.

It was requested that the Medical Board of Florida order one or more of the following penalties for the ED physician: 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 Medical Board of Florida deemed appropriate.

State: Florida

Date: December 2017

Specialty: Emergency Medicine

Symptom: Chest Pain, Back Pain, Chest Pain, Head/Neck Pain

Diagnosis: Aneurysm

Medical Error: Failure to order appropriate diagnostic test, Delay in proper treatment, Failure to examine or evaluate patient properly, Lack of proper documentation

Significant Outcome: Death

Case Rating: 4

Link to Original Case File: Download PDF

On 12/4/2013, a 78-year-old female presented to an ophthalmologist for phacoemulsification with posterior chamber implant (“cataract surgery”) on her right eye.

During the cataract surgery, the patient experienced a posterior capsule tear, a known complication and an accepted risk associated with cataract surgeries.

On 2/3/2014, the patient presented to the ophthalmologist for an examination, and the ophthalmologist noted inflammation in the patient’s operative eye.

On 3/27/2014, the patient presented to the ophthalmologist for an examination, and the ophthalmologist noted inflammation in the patient’s operative eye.

On 4/8/2014, the patient presented to the ophthalmologist for an examination, and the ophthalmologist noted that the patient experienced post-operative chronic iritis in her operative eye.

On 5/6/2014, the patient presented to the ophthalmologist for a follow-up examination of her operative eye.

On 8/14/2014, the patient presented to the ophthalmologist for a follow-up examination of her operative eye.

On 9/18/2014, the patient presented to the ophthalmologist and reported throbbing pain in her operative eye.

Despite knowing that the patient experienced a complicated cataract surgery, followed by persistent inflammation in her operative eye, the ophthalmologist did not perform a dilated examination until 9/18/2014.

Despite knowing the patient experienced a complicated cataract surgery, followed by persistent inflammation in her operative eye, the ophthalmologist did not refer her to a retina specialist.

The Board judged the ophthalmologist’s conduct to be below the minimum standard of competence given his failure to perform a dilated examination on the patient’s operative eye to investigate the causes of persistent post-operative inflammation within a reasonable time after the cataract surgery.  The ophthalmologist also failed to refer the patient to a retina specialist to investigate the causes of persistent post-operative inflammation within a reasonable time after cataract surgery.

The Board ordered that the ophthalmologist pay a fine of $2,500 against his license and that the ophthalmologist pay reimbursement costs for the case for a minimum of $4,634.56 but not to exceed $6.634.56.  The Board also ordered that the ophthalmologist complete five hours of continuing medical education in post-operative care and complete one hour of continuing medical education in “Risk Management.”

State: Florida

Date: November 2017

Specialty: Ophthalmology

Symptom: Head/Neck Pain, Swelling

Diagnosis: Post-operative/Operative Complication, Ocular Disease

Medical Error: Failure to examine or evaluate patient properly, Referral failure to hospital or specialist

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

On 7/13/2006 through 8/6/2013, a family practitioner treated a 37-year-old female for chronic neck and back pain.  The patient presented to the family practitioner with a history of hypertension, depression, anxiety, and back pain from a 2004 motor vehicle accident.

The patient’s medical records from her previous treating physicians indicated that the patient was addicted to Xanax, had attempted suicide via overdose of alcohol and Tylenol in 2004, and was a high-risk patient with regards to controlled substances.

Throughout the course of the treatment, the family practitioner prescribed controlled substances to the patient including Nucynta, Percocet, Xanax, Klonopin, Vicodin, and Soma.

On 10/7/2008, the family practitioner noted that the patient exhibited drug seeking behavior, had undergone physical withdrawals, and was having psychological dependence.  The family practitioner documented “no further controlled substances after this.”

On 10/7/2008, the family practitioner referred the patient to a pain management specialist.

From 10/17/2008 to 5/6/2010, the patient presented to a pain management specialist for her chronic pain.

Beginning on 5/17/2010, the patient discontinued treatment with the pain management specialist and resumed her treatment with the family practitioner for her chronic pain.

From 9/2/2011 through 8/6/2013, the patient presented to the family practitioner approximately every three months.  Despite the patient only presenting every three months, the family practitioner prescribed monthly refills of controlled substances for the patient.  The family practitioner prescribed Nucynta, Percocet, Xanax, Klonopin, Vicodin, and Soma to the patient in various combinations and amounts.

The prevailing standard of care requires that a physician treating a patient for chronic pain prescribe controlled substances appropriately.  The quantity and/or combination of controlled substances the family practitioner prescribed to the patient on one or more occasions from 9/2/2011 through 8/6/2013 were inappropriate.

The prevailing standard of care requires that a physician treating a high-risk patient for chronic pain create and implement an appropriate treatment plan.

The family practitioner did not create or implement, or did not document creating or implementing, an appropriate treatment plan for the patient.  The prevailing standard of care requires that a physician treating a high-risk patient for chronic pain evaluate the patient prior to refilling prescriptions for controlled substances.  On one or more occasions, the family practitioner prescribed multiple refills of controlled substances for the patient at a single office visit.

The prevailing standard of care required that a family physician treating a high-risk patient for chronic pain refer the patient to a chronic pain specialist.  The family practitioner did not refer, or did not document referring, the patient to a chronic pain specialist on or after 9/2/2011.

It was requested that the Board order one or more of the following penalties for the family practitioner: 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: August 2017

Specialty: Family Medicine

Symptom: Head/Neck Pain, Back Pain, Psychiatric Symptoms

Diagnosis: Drug Overdose, Side Effects, or Withdrawal

Medical Error: Improper medication management, Referral failure to hospital or specialist, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF

On 11/15/2013, a patient presented to the emergency department complaining of chest pain with radiation to the neck, throat, and back.  The patient expired the next day due to cardiac arrest.  The ED physician failed to perform a CT scan of the patient’s chest and failed to admit the patient for observation.  The ED physician discharged the patient with the diagnosis of “musculoskeletal chest pain.”

He was ordered a fine and to complete 5 hours of continuing medical education in each of the topics of medical record keeping and risk management.

State: Virginia

Date: August 2017

Specialty: Emergency Medicine

Symptom: Chest Pain, Back Pain, Head/Neck Pain

Diagnosis: Cardiovascular Disease

Medical Error: Diagnostic error

Significant Outcome: Death

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

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

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

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

State: New York

Date: April 2017

Specialty: Internal Medicine, Family Medicine

Symptom: Extremity Pain, Head/Neck Pain

Diagnosis: Deep Vein Thrombosis/Intracardiac Thrombus

Medical Error: Diagnostic error

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF

On 1/30/2013, a 33-year-old female presented to an ED physician with complaints of fever, cough, and sore throat, which began three days prior.  The patient also complained of shortness of breath.

The ED physician obtained the patient’s vital signs and performed a physical exam.

The ED physician noted the patient’s pulse oximetry was 91%.  He interpreted the patient’s pulse oximetry as “mild desaturation.”

The ED physician noted the patient’s heart rate was 129.  On cardiac exam, he found the patient to be tachycardic.

The ED physician ordered lab work.  The patient’s white blood cell count was found to be elevated at 20.4.  The patient was also found to have bandemia.

The ED physician ordered a chest x-ray.  He interpreted the chest x-ray as showing no infiltrate and no acute disease.  However, the radiologist later reported the chest x-ray as showing right middle lobe infiltrate worrisome for pneumonia.

The patient was administered ketorolac, acetaminophen, and intravenous fluids.

On re-evaluation, the ED physician noted that the patient had diffuse wheezing.

The ED physician discharged the patient home with a diagnosis of viral syndrome, cough, febrile illness, leukocytosis, and tobacco abuse.

The patient’s presentation was consistent with possible septicemia.

On 2/2/2013, the patient returned to the emergency department with complaints of high fever, cough with sputum, and shortness of breath.

The patient was subsequently diagnosed with bilateral pneumonia, septic shock, acute kidney injury, acute respiratory failure, bilateral pleural effusions, and pneumothorax, requiring admission to the hospital, and later transfer to the ICU, for approximately twenty days.

The Medical Board of Florida judged the ED physician’s conduct to be below the minimal standard of competence given that he failed to evaluate, or failed to document evaluating the patient’s septicemia.  He also failed to check, or failed to document checking the patient’s lactate level.  He failed to obtain, or failed to document obtaining blood cultures for the patient.  He failed to treat, or failed to document treating the patient for septicemia.  The ED physician failed to administer, or failed to document administering, IV antibiotics for the patient.  He also failed to recheck, or failed to document rechecking the patient’s vital signs prior to discharging her home.  He failed to admit, or failed to document admitting the patient to the hospital.

The Medical Board of Florida issued a letter of concern against the ED physician’s license.  The Medical Board of Florida ordered that the ED physician pay a fine of $5,500 against his license and pay reimbursement costs for the case at a minimum of $2,004.13 but not to exceed $4,004.13.  The Medical Board of Florida also ordered that the ED physician complete five hours of continuing medical education in diagnosis of septicemia and five hours of continuing medical education in “risk management.”

State: Florida

Date: February 2017

Specialty: Emergency Medicine

Symptom: Fever, Cough, Head/Neck Pain, Shortness of Breath

Diagnosis: Pneumonia, Sepsis, Pulmonary Disease, Pneumothorax

Medical Error: Diagnostic error, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Lack of proper documentation

Significant Outcome: Hospital Bounce Back

Case Rating: 4

Link to Original Case File: Download PDF

On 6/14/2011, a patient presented to an otolaryngologist on referral from another physician for evaluation of right-side ear pain, hearing loss, and drainage.  The otolaryngologist diagnosed a large right-sided tympanic membrane perforation, chronic sinusitis, and hearing loss secondary to chronic sinusitis and tympanic membrane perforation.

On 7/25/2011, the otolaryngologist ordered a CT scan and requested copies of the patient’s most recent hearing examination.  On 8/19/2011, the patient underwent a CT scan that did not show any significant sinus disease.  The otolaryngologist documented that the CT scan revealed chronic sinusitis and recommended endoscopic sinus surgery.  On 7/18/2012, the otolaryngologist performed endoscopic sinus surgery on the patient, which was complicated by right-sided CSF leak.  The otolaryngologist repaired the leak intra-operatively.

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 appropriately diagnose chronic sinusitis and performed endoscopic sinus surgery on a patient without an appropriate medical indication.  The otolaryngologist also failed to order audiological testing for the patient, consider tympanoplasty surgery, and admit the patient to the hospital after she suffered a right-sided 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: Hearing Problems, Head/Neck Pain, Wound Drainage

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

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

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF