Found 109 Results Sorted by Case Date
Page 10 of 11

Washington – Internal Medicine – 36-Year-Old Male With New Onset Chest Pain



On 5/28/2009, a patient saw an internist complaining of new onset chest pain.  The patient was a 36-year-old male, 5’9” and weighing 265 pounds, with borderline hypertension (blood pressure of 141/93) and a family history of diabetes.  The patient reported that a couple days prior to the visit, while on vacation, he experienced chest and/or abdominal pain that radiated to his left arm.  The patient took Alka-Seltzer and aspirin and the pain went away.  The chest pain reoccurred approximately two days later in the early morning hours of the office visit.  The patient reported that on that occasion he got out of bed, vomited, felt better, and went back to bed.  The patient indicated that he had never experienced anything like this before.

The internist obtained an electrocardiogram that indicated a T wave abnormality and possible anterior ischemia.  The internist prescribed Prilosec, ordered testing for H. pylori, and recommended an echo stress test for the following day, though the patient scheduled the stress test for the following week.  The internist advised the patient to seek medical attention if he experienced chest pain, heart palpitations, swelling, shortness of breath, or blood in the vomitus or stool.

Two days later, on 3/30/2008, the patient died from a myocardial infarction.

Based on the patient’s presentation with reports of chest pain radiating to his left arm with vomiting, the patient’s obesity, borderline hypertension, and the electrocardiogram results, the physician should have done further workup on this patient to rule out cardiac issues.

The Commission stipulated that the internist reimburse costs to the Commission, have his license be placed on probation, complete a continuing education course addressing the diagnosis and treatment of myocardial infarction, and write and submit a paper of at least 1000 words regarding the diagnosis and treatment of myocardial infarction.

State: Washington


Date: January 2010


Specialty: Internal Medicine


Symptom: Chest Pain, Nausea Or Vomiting, Extremity Pain


Diagnosis: Acute Myocardial Infarction


Medical Error: Diagnostic error, Delay in proper treatment


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Medicine – Gynecology – Abdominal Pain, Nausea, and Vomiting Following Hysteroscopy With Biopsy And D&C



On 01/31/2008, a 76-year-old woman saw a gynecologist for evaluation of post-menopausal bleed.  It was agreed that a tissue evaluation would be required to evaluate for endometrial cancer.

On 03/12/2008, the gynecologist performed a hysteroscopy with biopsy/D&C at a surgical center.  The gynecologist believed that she had perforated the uterus, but that the perforation was not significant due to the shallow depth of placement of the instruments.  She expected the uterine perforation would heal spontaneously and rejected the idea of performing a laparoscopy.  She did not see the patient after she left the operative suite.  She told the family that she had perforated the uterus and instructed them to call if the patient had symptoms of pain, fever, or nausea.  The patient was discharged home at 10:30 a.m., 2 hours after the surgery.  At 11:50 a.m., the gynecologist was summoned to attend a patient’s delivery and was preoccupied until 1:00 p.m.

After arriving home, the patient began to have acute abdominal pain and nausea associated with uncontrollable vomiting.  At 12:00 p.m., the patient’s daughter called the surgical center, described the patient’s symptoms, and requested a call back from the gynecologist.  At 12:48 p.m., having not yet heard from the gynecologist, the daughter called the surgical center and requested that the gynecologist call immediately.

The gynecologist did not receive the family’s first telephone message and received the second message via a page at approximately 1:00 p.m.  The gynecologist was concerned that the patient’s symptoms suggested a possible bowel perforation and advised the patient to be brought to the emergency department.

At 2:00 p.m., the patient presented to the emergency department.  The gynecologist did not go to the emergency department, but monitored the patient’s lab work and x-rays remotely.  WBC was 2.5 with a left shift, which concerned the gynecologist.  X-ray of the abdomen showed no free air.

At 5:00 p.m., the gynecologist called the emergency department.  The ED physician reported that the CT scan demonstrated air and fluid in the abdomen with signs of bowel injury.  The gynecologist informed the ED physician that she would be arranging surgery and would see the patient.

At 5:30 p.m., the gynecologist arrived at the hospital.  The gynecologist and the general surgeon discovered and repaired a puncture to the patient’s bowel and uterine wall.  The patient was expected to recover.

On 03/13/2008, the patient’s condition became critical.  She became hypotensive.  An echocardiogram revealed global cardiac dysfunction.  A cardiac balloon pump was placed with no effect.  The patient underwent dialysis.  The gynecologist went to the hospital three times that morning and maintained contact with the family.

At 8:00 p.m. that day, the patient died.

In March of 2009, the gynecologist obtained 18.25 AMA PRA Category 1 CME credits by completing “An Overview of Perioperative Medicine 2009,” offered by the Mayo Clinic School.

In May of 2009, the gynecologist attended the ACOG Annual Clinic Meeting and obtained 6 hours of CME by completing “Hands-on Operative Hysteroscopy.”

The Board ordered the gynecologist be reprimanded and pay the costs of the proceeding.

State: Wisconsin


Date: May 2009


Specialty: Gynecology


Symptom: Gynecological Symptoms, Nausea Or Vomiting, Abdominal Pain


Diagnosis: Post-operative/Operative Complication


Medical Error: Procedural error, Underestimation of likelihood or severity


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Kansas – Physician Assistant – Fever, Sweats, Malaise, Nausea, And Vomiting Diagnosed As Food Poisoning



A 63-year-old male presented to the emergency department on 6/29/2006, complaining that he had awakened the previous night with a fever of 102 degrees, sweats, malaise, nausea and one episode of vomiting.

A physician assistant diagnosed the patient with food poisoning.  The physician assistant’s treatment plan for the patient included admitting him to the hospital; however, the patient did not want to be admitted.  The physician assistant failed to document in the medical record for the patient the degree and effort to which she attempted to admit the patient.  The physician assistant failed to document specific instructions to the patient.  The physician assistant failed to create and maintain adequate medical records for the patient.

The Board ordered that the physician assistant complete a continuing medical education course for medical record keeping by the Center for Personalized Education for Physicians (CPEP).

State: Kansas


Date: April 2009


Specialty: Physician Assistant


Symptom: Fever, Nausea Or Vomiting, Weakness/Fatigue


Diagnosis: Gastrointestinal Disease


Medical Error: Physician concern overridden, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Arizona – Orthopedic Surgery – Serous Drainage Accompanied By Headache, Fever, Vomiting, And Nausea Post Spine Surgery



On 09/23/2005, the orthopedic spinal surgeon performed surgery on a 24-year-old man with a three-year history of low back pain and numbness in his right leg and foot from a motor vehicle accident in 2001.

His report documented transforaminal lumbar interbody fusion of L4-L5, interbody cage placement at L4-L5, and posterior instrumentation and fusion with pedicle screw fixation.

On 09/24/2005, a physician evaluated the patient while he was in the hospital for a complaint of headache.  According to his consultation note, his impression was that the patient had a “migraine HA.”

On 09/26/2005, the patient was discharged from the hospital.

On 10/18/2005, the orthopedic spinal surgeon documented that the patient had increasing pain in his lower back and serous drainage.  There was some redness around the incision.  The patient reported that he had taken a neighbor’s ciprofloxacin for a few days.  The orthopedic spinal surgeon continued the patient on ciprofloxacin because “[a]ny time you have significant drainage it can increase the risk of infection…”

On 11/08/2005, the orthopedic spinal surgeon documented that the patient had increasing back pain, fever at night, nausea, and vomiting.  He recommended surgical drainage.

On 11/10/2005, the orthopedic spinal surgeon performed irrigation and debridement of the lumbar spine wound with closure over a drain on the patient.  He noted no purulence, but did note an intense amount of drainage from the “seroma.”

On 11/12/2005, the patient was discharged.

The patient was continued on antibiotics and continued to experience pain in his lumbar spine, which the orthopedic spinal surgeon continued to attribute to the seroma rather than an infection.

On 11/22/2005, the orthopedic spinal surgeon documented in his progress note that the patient was “going to try to go back to work fairly soon.”

On 12/20/2005, the orthopedic spinal surgeon noted that the patient probably had a cerebral spinal fluid (CSF) leak.  The orthopedic spinal surgeon stated that “I did not have a CSF leak during my surgery but the patient did have only preoperatively after his IDET procedure.  He had a successful blood patch because of this by [a different physician] and I think maybe he has a recurrence of this dural leak.  Why it would happen at this time frame I have no idea but it looks like it is.”

On 03/11/2005, the patient had undergone surgery by a different physician for an interlaminar epidural injection and blood patch at L4-L5.

On 12/22/2005, the orthopedic spinal surgeon performed a dural repair and placed blood patches on the patient.  The operative report documented his lumbar laminectomy for a dural leak at L4-L5 with scar revision and dural repair.  He noted that he could not localize an anterior dural tear, but placed Duragen and fibrin glue around the dura.

On 12/28/2005, another physician evaluated the patient for headaches and noted that the patient had post-surgical meningitis improving with antibiotics and recommended transfer to a neurologist.

On 12/30/2005, a neurologist evaluated the patient and noted that his lumbar puncture revealed evidence of bacterial meningitis.

The neurologist reviewed a 12/29/2005 myelogram and noted a left paramedian CSF leak or pseudomeningcoele.  A CT scan from the same day reported that there was left posterior paramedian thecal sac dehiscence.  The neurologist noted a screw tract medial to the screw site used on the left and recommended neurosurgical exploration.

On 01/18/2006, the patient returned to surgery for dural repair to be performed by a different surgeon, Surgeon A.  His operative report documented his laminectomy at L4-L5 with a porcine collagen patch repair of a large posterior dural defect and placement of a drain.  He noted that after a complete laminectomy there was ligamentum flava adherent to the dura and after removal, he found a large posterior dural defect.

Throughout 2007, the patient continued to require pain management with fentanyl patches and oxycodone/acetaminophen.  A recent MRI in 2007 revealed post-operative changes of laminectomy and fusion and interpedicular screws at L4-L5, clumping of the roots from L3 through L5, and extensive scarring at L4-L5.

The orthopedic spinal surgeon testified at a hearing that the incidence of a dural tear during spinal surgery is between 6 and 8%.  His incidence was around 9% despite doing a lot of revision surgery.

A Medical Consultant, who was the orthopedic spinal surgeon’s partner, testified that the patient’s symptoms were consistent with an infection after the first surgery and that the patient did not have signs and symptoms of a dural tear up until the second surgery.  He further testified that the 12/02/2005 MRI showed no fluid collection, which would have been expected if the patient had an undiagnosed dural tear.  He also testified that when the patient did not improve, a second surgery was performed by two spinal surgeons (the orthopedic spinal surgeon and his partner) and that they appropriately treated the suspected leak even though they could not find it.

The Board judged orthopedic spinal surgeon’s conduct to be below the minimum standard of competence given failure to diagnose CSF leak in a timely fashion.  Clear serous draining post spine surgery should raise concern for a CSF leak, which should be timely addressed to prevent the possibility of infection.  His progress note documented a mechanism for the dural tear that was inconsistent with the histories obtained by other physicians.  The Board had established that the orthopedic spinal surgeon created a dural tear posteriorly on 09/23/2005, which was unrelated to the area of the IDET procedure, and that he failed to diagnose a CSF leak for almost eight weeks despite having surgically revisited the area.  He failed to correlate the non-purulent fluid with a possible CSF leak.

As a result of the delayed diagnosis of the tear, the patient sustained bacterial meningitis.  He requires fentanyl patches given arachnoiditis as seen on an MRI.

The Board reviewed complications of this case among many others that involved the orthopedic spinal surgeon.  They remained concerned that the orthopedic spinal surgeon continued to insist that he made no mistakes in the care of his patients despite being confronted with the evidence.  The Board ultimately ordered his license to be revoked.

State: Arizona


Date: February 2009


Specialty: Orthopedic Surgery


Symptom: Back Pain, Fever, Nausea Or Vomiting, Numbness


Diagnosis: Post-operative/Operative Complication, Spinal Injury Or Disorder


Medical Error: Diagnostic error, Procedural error


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Wisconsin – Medicine – 74-Year-Old Woman With Severe Abdominal Pain, Nausea, And Emesis Found To Have Cholecystitis and Hydronephrosis



On 07/06/2003, a 74-year-old woman presented to the emergency department with severe abdominal pain, nausea, and emesis.  CT abdomen and pelvis with IV and enteric contrast revealed a dilated and inflamed gallbladder, severe left-sided hydronephrosis with complete dilation of the left collecting system and an abnormal soft tissue density at the left bladder base, and mild to moderate hydronephrosis down to the ureteropelvic junction on the right with some questionable soft tissue density.  The patient was diagnosed with acute cholecystitis.  A general surgeon performed laparoscopic cholecystectomy.  Pathology revealed acute suppurative cholecystitis and benign cystic duct lymph node.

On 07/07/2003, the patient was discharged.  The general surgeon documented the secondary diagnosis of hydronephrosis and a recommendation to follow up with a urologist in his progress notes.

However, his physician assistant dictated the discharge summary and did not include in his dictation the recommendation to follow up with a urologist.

On 07/14/2003, the general surgeon saw the patient for a follow-up.  The patient was not referred to a urologist.

On 03/22/2004, the patient presented to a gynecologist complaining of vaginal bleeding despite having had a hysterectomy in 1988.  She was referred to a urologist.

On 04/21/2004, the patient was diagnosed with bladder cancer.

The general surgeon met with the patient and her family and apologized for the failure to follow up on the CT scan results.

In June of 2005, the patient was placed on hospice, and she died of metastatic bladder cancer on 09/28/2005.

The general surgeon, as chair of the surgery department, worked on a program to improve continuity of care, specifically pertaining to the transition from inpatient to outpatient status.

The general surgeon was also involved in the implementation and integration of an electronic medical record system designed to improve continuity of care.

The Board ordered the general surgeon to pay the costs of the proceeding.  He was recognized for his work on continuity of care.

State: Wisconsin


Date: August 2008


Specialty: General Surgery


Symptom: Abdominal Pain, Nausea Or Vomiting


Diagnosis: Cancer


Medical Error: Failure to follow up, Failure of communication with other providers


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Wisconsin – General Surgery – Abdominal Pain, Tachycardia, Nausea, Vomiting, And Dizziness After Appendectomy



On 8/30/2004, an appendectomy was performed on a seven-year-old patient.  The patient initially recovered well, but that evening he began to experience increasing abdominal pain, nausea, and vomiting.  The surgeon was alerted by nursing staff.  He ordered a CT scan and changed one of the ordered pain medications but did not come to evaluate the patient.  The patient continued to have, intermittently, pain, nausea, and dizziness.  Beginning on 9/1/2004, and continuing into 9/2/2004, the patient was tachycardic with heart rates in the 140s to 180s.  Bowel sounds were hypoactive.

The surgeon felt the CT scan findings suggested a post-operative ileus.  On 9/1/2004, the surgeon saw the patient and ordered a nasogastric tube for decompression, with no improvement.  The patient’s pain, nausea, and vomiting continued.

The patient was seen by the surgeon on 9/2/2004.  The patient’s mother contends that the surgeon told her that the patient was “just acting out.”  The surgeon denies this contention.  He stated that he would have considered discharge if the patient remained more comfortable.  At this time, the patient’s heart rate was 166-186.

The patient’s mother terminated the surgeon’s services to her son.  The surgeon requested a pediatric consult.  The pediatrician found an acute abdomen with evidence of distention, guarding, and absent bowel sounds.  The nasogastric tube was replaced and a significant amount of bilious fluid in the stomach was evacuated.  Symptoms of dehydration were noted.  Although the patient’s white count was normal, his hemoglobin and hematocrit had dropped by 4 grams.  An x-ray evaluation suggested a bowel obstruction with dilated loops of small bowel and associated air-fluid levels.  Chest x-ray revealed a right lower lobe infiltrate with air bronchograms and evidence of moderate-sized pleural effusion.

The Chief of Surgery then evaluated the patient.  His differential diagnosis was post-operative hemorrhage versus post-operative small-bowel obstruction with bowel compromise.  Because there was a significant chance the patient would need post-operative mechanical ventilation, the Chief of Surgery ordered him to be airlifted to the Children’s Hospital for immediate surgery.

It was determined during surgery that the patient had a distal small bowel volvulus involving 105 cm of mid to distal bowel.  No resection of the bowel was required, as the bowel immediately pinked up.  The patient recovered and was discharged to home on 9/10/2004.

The Board ordered the surgeon pay the costs of the proceeding and complete eight hours of continuing education in pediatric surgical post-operative complications.

State: Wisconsin


Date: November 2007


Specialty: General Surgery, Pediatrics


Symptom: Abdominal Pain, Nausea Or Vomiting


Diagnosis: Post-operative/Operative Complication, Acute Abdomen


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



Wisconsin – Emergency Medicine – Stumble Leads To Epigastric And Back Pain And Shortness Of Breath



On 11/11/2002, a 32-year-old woman with a history of chronic back pain secondary to scoliosis presented to a chiropractor’s office with severe stabbing pain and shortness of breath.  Her symptoms occurred when she stumbled while exiting a vehicle with a step off ledge high above the ground.  When she arrived, she laid on the floor and then vomited after arising.  EMS was contacted and noted on arrival a woman sitting on a chair.  She reported having sudden onset of back and epigastric pain.  She was screaming in pain and writhing in the gurney.  She was transported to the emergency department.  The triage nurse noted a sharp 7/10 pain.  She was emotional given that her father had recently died and the funeral was that day.  Vitals were BP 115/80, HR 178, RR 32, and temperature 96 degrees.

At 1:45 p.m., an IV was placed, labs were drawn, and an EKG was performed revealing sinus tachycardia.  Family Practitioner A noted complaints of epigastric pain and shortness of breath.  Physical exam revealed a chest wall and epigastrium that were nontender to palpation.  Lung fields were clear.  She had tachycardia and pallor.  Blood sugar was 211.  Urinalysis revealed trace ketones.  WBC 9.3, platelets 442, sodium 140, potassium 3.9, chloride 106, and carbon dioxide 25.  Liver function test was normal.  Family practitioner A documented diagnoses of hyperglycemia, dehydration, back pain, tachycardia, anxiety, and acute cystitis.  He ordered 2 L of fluid, hydroxyzine 50 mg IM, ranitidine 50 mg, and nalbuphine.

She improved and was discharged at 5:10 p.m.  Family Practitioner A ordered a 3 hour glucose tolerance test for the following morning.  At discharge, she was prescribed paroxetine, lorazepam, valdecoxib, and nitrofurantoin.

After discharge, the patient asked a relative to return her to the chiropractor’s office.  The chiropractor adjusted her spine and noted pallor, tachycardia, and hypotension.  He advised that the patient immediately return to the emergency department.

At 6:05 p.m., she returned to the emergency department, where her blood pressure was 100/?, HR 143, RR 12.  The triage nurse noted that the patient had been partially non-responsive at the chiropractor’s office.  The patient reported chest tightness and pain, back spasms, and shortness of breath.  The nurse noted that she believed the patient’s symptoms to be related to her father’s death.  She could not lie down without pain.  Family Practitioner A noted that the patient had had a near syncopal event at the chiropractor’s office.  He diagnosed stress reaction, anxiety, and side effect secondary to the nalbuphine.

Physician B took over care at 8:10 p.m. to resume care.  She reported that Family Practitioner A told her to discharge the patient with a follow-up if not improved.  Labs were normal and the patient was discharged at 9:50 p.m. with social services referral and recommendation for a follow-up if not improved.

From 11/11/2002 to 11/14/2002, the patient continued to have symptoms of chest, side, and back pain along with shortness of breath and weakness.  On 11/14/2002, she presented to the emergency department again with a blood pressure of 180/106, pulse of 144, and respiratory rate of 24.  The triage nurse documented 6/10 pain in the left rib area and sharp pain when lying back.  Physician C documented that the chest pain and shortness of breath was worse when the patient was lying down.  On exam, the patient was noted to be hypertensive, with tachycardia, and with diminished breath sounds on the right side.  The breath sounds were absent at the right base with some crackles on the left side.  Both legs had pitting edema.  Chest x-ray revealed a large right pleural effusion and severe scoliosis.  CT scan of the chest revealed bilateral pulmonary contusions with very large right hemithorax and question of left pneumothorax.  There was concern for a right 5th rib fracture with laceration of the costal artery leading to the hemothorax.  Physician C diagnosed large right hemithorax, anemia, severe scoliosis, neurofibromatosis, and suspected 5th rib fracture.  She was transferred to a hospital where there was a thoracic surgeon.

The Board judged that Family Practitioner A’s care of the patient fell below minimum standards of care by not evaluating her properly on 11/11/2002 and obtaining a CXR.  The Board ordered 15 hours of CME in the evaluation and treatment of cardiothoracic injuries.

State: Wisconsin


Date: January 2007


Specialty: Emergency Medicine, Family Medicine


Symptom: Back Pain, Nausea Or Vomiting, Abdominal Pain, Shortness of Breath


Diagnosis: Fracture(s), Pulmonary Disease


Medical Error: Failure to order appropriate diagnostic test


Significant Outcome: Hospital Bounce Back


Case Rating: 4


Link to Original Case File: Download PDF



Wisconsin – Emergency Medicine – Epigastric pain, Back Pain, And Shortness of Breath After Stumbling While Exiting A High Clearance Vehicle



On 11/11/2002, a 32-year-old female patient presented to a chiropractic office with complaints of severe stabbing pain and shortness of breath after stumbling while exiting a high clearance vehicle. Upon arrival to the office she lay down on the floor and when arising, she vomited.  Emergency medical services were immediately contacted and upon arrival at the chiropractic office noted the patient to be sitting in a chair with complaints of epigastric and back pain with sudden onset.  When assisted to a cot, the patient was noted to be very anxious, rolling on the cot and screaming in pain.

Upon arrival at the emergency department, the triage nurse noted the following symptoms: sudden onset of epigastric pain that radiated to the back and emesis.  The pain was noted as a sharp 7/10 pain.  The patient was emotional given that her father had recently passed away.  The funeral was that day.  The patient had chronic back pain due to scoliosis.  The patient’s vitals upon arrival were noted by the nurse as 115/80 BP, 178 radial pulse, respirations at 32, and temperature of 96 degrees.

At 1:45 pm, an IV was started, samples for laboratory analysis were taken, and an EKG was performed and was interpreted as sinus tachycardia, otherwise normal.  ED physician A provided a medical evaluation and noted the patient’s chief complaint as epigastric pain and difficulty breathing.  His physical examination revealed she had poor respiratory movement; however, her lung fields were clear bilaterally.  The chest wall and epigastrium were nontender to palpation.  The heart was tachycardic without murmurs or rubs.  The patient’s skin was pale.  The patient’s blood sugar was 211 and urinalysis showed trace ketones.  The patient’s white blood count was 9.3; elevated platelets were 442, sodium was 140, potassium was 3.9, chloride was 106, and carbon dioxide was 25.  She had a normal liver panel.

ED physician A believed the patient’s tachycardia may have been due to dehydration and ordered 2 liters normal saline administered. ED physician A diagnosed hyperglycemia, dehydration, back pain, tachycardia, anxiety, and acute cystitis and ordered 50 mg of hydroxyzine IM, 50 mg of ranitidine for both nausea and anxiety, and 10 mg of nalbuphine IV.  The patient’s condition improved while in the emergency department and the patient was discharged at 5:10 pm with an appointment for a 3 hour glucose tolerance test the following morning.

Upon discharge the patient was prescribed paroxetine, lorazepam, valdecoxib and nitrofurantoin.  After discharge, the patient was, at her request, returned to the chiropractic office.  The treating chiropractor adjusted the patient’s spine and noted her to be very pale with a rapid pulse and no detectable blood pressure.  He advised the relative to return the patient to the emergency department. The patient returned to the emergency department at 6:05 pm.  At that time her blood pressure was noted as 100/?, pulse at 143 and respirations at 12.

The triage nurse noted the patient had been hypotensive and partially non-responsive at the chiropractor’s office.  The patient complained of chest tightness and occasional back spasms and chest pain.  The nurse noted the patient was having a difficult time dealing with her father’s death and assessed the patient as suffering stress due to that death.  The patient advised staff that her back and chest hurt and she had some difficulty breathing.  She was unable to lie down without pain.  An IV was placed for saline administration and samples for basic metabolic laboratory analysis were drawn.

ED physician A examined the patient and noted a near syncopal episode in the chiropractic office.  He diagnosed a stress reaction and reaction to the previously administered nalbuphine.  He further noted that a readmission history and physical would be performed by ED physician B.

ED physician A did not order an x-ray of the patient’s chest area. ED Physician B noted that the patient was endorsed to her at 8:10 pm and the care provided solely per ED Physician A’s plan.  She noted the patient was receiving normal saline for dehydration and basic metabolic laboratory work was performed. According to ED Physician B,  ED Physician A had advised her to discharge the patient with instructions to the patient to follow-up with another physician for re-evaluation if not feeling better.  The laboratory analysis was normal and the patient was discharged at 9:50 pm with a social services referral and instructions to follow up for re-evaluation if not better. Based on ED Physician A’s diagnoses, the patient believed she was suffering from anxiety.

Between discharge on 11/11/2002 and 11/14/2004, the patient suffered continued back, side and chest pain, with difficulty breathing and weakness.  On 11/14/2004 at 1:44 am, the patient was readmitted to the emergency department with a blood pressure of 180/106, pulse of 144 and respirations at 24.  The triage nurse noted a chief complaint of pain in the left rib area, 6/10, with a sharp pain when lying back.

The patient denied chest pain. ED Physician C, examined the patient and noted chest pain and shortness of breath which was worse when lying down.  He noted high blood pressure, tachycardia with no gallop or murmur, diminished breath sounds on the right side and absent at the right base with some crackles on the left side and pitting edema in both legs.  ED Physician C ordered a chest x-ray which revealed a large right pleural effusion and severe scoliosis.

A CT scan of the chest revealed bilateral pulmonary contusions with a very large right hemothorax and suggestion of a pneumothorax on the left. He further suspected a right 5th rib fracture which may have lacerated a costal artery and caused the hemothorax. ED Physician C diagnosed a large right hemothorax, anemia, severe scoliosis, neurofibromatosis, and suspected 5th rib fracture and arranged immediate transfer to another hospital for treatment by a thoracic surgeon.

The Board judged Physician A’s conduct to be below the minimum standard of competence given failure to properly evaluate the patient’s condition upon her return to the emergency department at 6:05 pm on 11/11/2002.  He failed to obtain a chest x-ray of the patient which was indicated by the patient’s symptoms.   Because of these failures, he did not reach the correct diagnosis of the patient’s condition creating the risk of delayed treatment of the hemothorax and fractured rib.

The Board ordered Physician A pay the costs of the proceeding and complete fifteen hours of continuing education in the evaluation and treatment of cardiothoracic injuries.

State: Wisconsin


Date: January 2007


Specialty: Emergency Medicine, Family Medicine, Internal Medicine, Trauma Surgery


Symptom: Chest Pain, Nausea Or Vomiting, Back Pain, Shortness of Breath


Diagnosis: Trauma Injury, Hemorrhage, Fracture(s)


Medical Error: Failure to order appropriate diagnostic test


Significant Outcome: Hospital Bounce Back


Case Rating: 5


Link to Original Case File: Download PDF



Wisconsin – Emergency Medicine – Cysts In The Perirectal Area



At approximately 4:00 p.m. on 11/14/1998, an obese 41-year-old man presented to the emergency department complaining of pain.  He was first seen by an RN:

1) The patient stated he had a cyst in the right groin area about 3” by 7” in size. He said he first noticed it about 3 days earlier.  He also said he had the same thing 6 years ago, which was treated with medication.

2) The patient said he had taken aspirin for the pain and he was not eating.

3) The RN took the patient’s vital signs and recorded his temperature as 99.5°, his blood pressure as 124/81, his pulse as 107, and his respirations as 16.

4) When asked by the RN to assess his pain on a scale of 0-10, the patient said “12.”

5) The patient was then seen by the ED physician in the emergency department.

The ED physician noted that the patient reported the following:

1) Complaints of a cyst localized to the right perirectal area, which had been present for three or four days.

2) Pain then localized to the rectal area.

3) A similar appearing lesion present a few years earlier which was resolved by treatment with oral antibiotics.

4) Decreased appetite and energy, fevers and chills.

The ED physician recorded that the patient was in no acute distress and noted the results of his examination as: “[E]xam of the perirectal area reveals there is a hard well encapsulated non-mobile markedly tender erythematous lesion noted right at the perirectal area.  The raised area measures approximately around 4 cm in diameter.  Skin is intact.  No areas of drainage.”  The ED physician recorded his assessment of the patient’s condition as a perirectal cyst.  Although not recorded, the ED physician recognized that the lesion was infected.

The ED physician then conducted the following:

1) Gave the patient a prescription for 20 units of Cipro 500 mg, to be taken one tablet twice a day for 10 days.

2) Gave the patient a prescription for 12 units of Tylenol #3, to be taken 1 tablet every 4-6 hours as needed.

3) Provided the patient with an intramuscular injection of 60 mg Toradol.

4) Instructed the patient to soak in baths with Epsom Salt.

5) Instructed the patient to follow up with his primary care practitioner for a possible incision and drainage, if symptoms did not improve in three or four days.

6) Discharged the patient from the emergency department.

The ED physician’s conduct in providing care to the patient fell below the minimal level of competence for a physician in that the ED physician:

1) Failed to order a complete blood count (CBC), which would have provided him with additional information about the seriousness of the infection.

2) Failed to recognize the lesion as an abscess based on the symptoms.

3) Failed to perform a needle aspiration or incision and drainage to determine if fluid was present, which would rule out cellulitis and confirm the condition as an abscess.

4) Failed to perform, or seek a consultation so another physician could perform, an incision and drainage of the abscess to remove the infected fluid.

The ED physician’s failures subjected the patient to the additional risks of harm that the infection would become worse, involve more tissue, and become septicemia.

At approximately 9:30 p.m. the next day, the patient returned to the emergency department and was seen by the same RN and a different physician.  The patient reported the following:

1) His pain on a scale of 0-10, as “13.”

2) Progressive pain and swelling in the area of the perineum since the previous visit.

3) Marked pain and swelling in the scrotum.

4) Some discomfort in both inguinal areas and in the suprapubic area.

5) Intermittent diaphoresis.

6) Intermittent chills and fever in the 101 to 104 range.

7) Nausea and vomiting several times.

The physician reported his exam of the area as: “The scrotum is markedly swollen to the point where it is very tense.  The scrotal skin is erythematous, somewhat edematous, indurated and markedly tender to palpation. The perineal area shows marked induration and tenderness without obvious drainage fluctuance, or crepitance.”  Laboratory results: White blood cell count of 24.5 with 78 segs, 6 bands. Hct of 46.9. Glucose 123. BUN 15. Creatinine 1.2. Sodium 134. Potassium 3.6. Chloride 99. AST 13. Alkaline phosphatase 89. Bilirubin 2.4.

The patient was immediately transferred to another hospital for evaluation and treatment.  The patient was taken to the operating room for incision and drainage of the abscess and removal of necrotic tissue.  It was then discovered that the entire perineal area was involved and the patient was diagnosed with Fournier’s gangrene, subsequently resulting in the loss of his right testicle.

The Board ordered that the ED physician pay the costs of the proceeding, be reprimanded, and complete 12 hours of continuing education in the assessment, diagnosis, and treatment of infectious processes or other conditions in the perirectal or perineal areas.

State: Wisconsin


Date: September 2006


Specialty: Emergency Medicine, Internal Medicine


Symptom: Pelvic/Groin Pain, Fever, Nausea Or Vomiting


Diagnosis: Necrotizing Fasciitis


Medical Error: Diagnostic error


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


Case Rating: 4


Link to Original Case File: Download PDF



Wisconsin – Family Practice – Nausea, Vomiting, Loose Stools, Weakness, Poor Appetite, And Weight Loss



An 89-year-old woman presented with nausea, vomiting, loose stools, weakness, poor appetite ,and weight loss from 4/30/01 to 5/11/01.  She lived at a health care facility.  Her daughter was her power of attorney.

On 5/11/01, the staff at the health care facility made an appointment for her to be scheduled at 11:15 a.m. on 5/11/01.  Physician A prescribed tetracycline for an infected ulcer on her right foot and metoclopramide for the patient’s nausea.  The patient returned to the health care facility.  She continued to have symptoms of nausea, vomiting, and poor appetite from 5/11/01 to 5/14/01.

On 5/14/01, the staff notified Physician A that her symptoms had continued.  CT scan of the abdomen, pelvis, and chest was ordered with oral contrast only.  On 5/14/01 at 2:25 p.m., a basic metabolic panel was ordered and completed on 5/14/01 at 3:11 p.m.  The laboratory report revealed Na 144, K 4.3, Cl 104, CO2 19.3, BUN 153, Ca 9.8, Cr 4.4, and glucose 114.  The results were called to the care facility at 3:10 p.m. on 5/14/01.  At 4 p.m., The staff notified Physician A of the lab results.  He discontinued a diuretic the patient was taking.  On 5/14/01, CT scan of the chest was obtained, and on 5/15, CT abdomen and pelvis was obtained with oral contrast, first bottle at 6 a.m. and second bottle at 7 a.m.

On 5/16/01, the radiologist noted that there was a large amount of oral contrast that had accumulated in a dilated stomach.  There was an incomplete mechanical small bowel obstruction with marked distention of the urinary bladder, and diverticulosis of the descending and sigmoid colon.  The radiologist recommended placement of the nasogastric tube.  The radiologist report was transcribed and made available on 5/16/01.

At 8:05 a.m. on 5/16/01, the nurse noted that the patient’s extremities appeared cyanotic, axillary temperature was 93.7, blood pressure 146/80, heart rate 120, respiratory rate were 40, and oxygen saturation was 97% on room air.  At 9:15 a.m., HR 122, axillary temperature 94.1, and oxygen saturation 84%.  At 9:20 a.m., axillary temperature was 95.5, heart rate 88-100, respiratory rate 28, and oxygen saturation was 94% on room air.  At 10 a.m., Physician A contacted the nurse, who updated him.  At this time, Physician A was not aware of the CT scan results.  He ordered prochlorperazine suppositories for nausea every 12 hours as needed.

On 5/17/01, Physician B took over care for the patient.  At 7:00 a.m., the staff noted that blood pressure was 60/42, respiratory rate 18, and pulse was 112.  Lying in bed, blood pressure was 100/60.  Bowel sounds were diminished.  At 9:30 a.m., the patient was poorly responsive.  She complained of pain in her abdomen.  At 9:30 a.m., the nurse paged Physician B, who returned the call at 10:15 a.m.

The nurse informed Physician A of the results of the CT scan.  Physician A ordered soap suds enemas and a clear liquid diet.  Staff administered two soap suds enemas with result of a moderate amount of liquid stool.  The nurse noted that there was blood in the stool.  At 2:30 p.m., the nurse notified Physician A of the results of the enema, who then ordered repeat of the soap suds enema along with administration of bisacodyl tablets.  At 5 p.m., the patient developed cardiorespiratory arrest and expired.

The Board decided that Physician B’s conduct was below the minimum standard of care and that nasogastric tube should have been considered as an option in this patient.  The Board ordered completion of 30 credit hours of CME in a gastroenterology review course.

State: Wisconsin


Date: July 2006


Specialty: Family Medicine, Gastroenterology, Internal Medicine


Symptom: Abdominal Pain, Nausea Or Vomiting, Weakness/Fatigue


Diagnosis: Acute Abdomen


Medical Error: Improper treatment, Failure to follow up


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



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