Found 109 Results Sorted by Case Date
Page 11 of 11

Wisconsin – Family Practice – Ordering Of CT Scans With Oral Contrast Or X-Ray Series For Possible Bowel Perforation Or Obstruction



An 89-year-old female patient resided at a health care facility for the last two years.  The patient’s daughter had the health care power of attorney for the patient.  The patient had on file with the health care facility an advanced directive status of “do not resuscitate”.

Over the period from 4/30/2001 through 5/11/2001 the patient experienced symptoms of nausea, vomiting, loose stools, weakness, poor appetite and weight loss.  On 5/11/2001, the staff at the health care facility contacted the patient’s family practitioner’s office and scheduled the patient for an appointment with the family practitioner at his office on 5/11/2001.

On 5/11/2001, the family practitioner examined the patient at his office and prescribed tetracycline for an infected ulcer on the patient’s right foot.  He also ordered metoclopramide for the patient’s nausea.  The patient returned to the health care facility following her appointment with her family practitioner.

The patient continued to experience nausea, vomiting, and a poor appetite from 5/11/2001 through 5/14/2001.  On 5/14/2001, the family practitioner was notified by the staff at the health care facility of the patient’s continuing nausea, vomiting, poor appetite, and weight loss.  The family practitioner ordered a CT scan of the patient’s chest and a CT scan of the patient’s abdomen and pelvis to be performed with oral contrast only.  The family practitioner also ordered a basic metabolic panel.

The specimen for the basic metabolic panel was collected at 2:25 p.m. on 5/14/2001 and the laboratory analysis and report were completed by 3:11 p.m. on 5/14/2001.  The laboratory report recorded as follows: Sodium 144 (136 – 145). Potassium 4.3 (3.5 – 5.0). Cl 104 (98 – 108) Carbon Dioxide 19.3 (24 – 32). Blood Urea Nitrogen 153 (7 – 18). Calcium 9.8 (8.8 – 10.5). Creatinine 4.4 (0.6 – 1.3). Glucose 114 (70 – 110).

The staff at the health care facility contacted the family practitioner at 4 p.m. on 5/14/01 and advised him of the laboratory values for the sodium, the blood urea nitrogen, and the creatinine.  The family practitioner ordered that the diuretic the patient was taking be discontinued.

The CT scan of the patient’s chest was obtained on 5/14/2001 and the CT scan of the patient’s abdomen and pelvis were obtained on 5/15/2001.  The staff at the health care facility administered the first bottle of oral contrast for the CT scan of the abdomen and pelvis to the patient commencing at 6 a.m. on 5/15/2001 and administered the second bottle of oral contrast commencing at 7 a.m. on 5/15/2001.

On 5/16/01, the radiologist read the CT scans of the patient’s chest and of the patient’s abdomen and pelvis.  He read the CT scan of the abdomen and pelvis as demonstrating a large amount of oral contrast accumulated within a dilated stomach and in the proximal small bowel consistent with an incomplete mechanical small bowel obstruction, marked distension of the urinary bladder, and diverticulosis of the descending and sigmoid colon.  The radiologist recommended placement of a nasogastric tube.  The radiologist dictated his radiology report making these findings and recommendations on 5/16/2001 and this radiology report was transcribed on 5/16/2001.

At 8:05 a.m. on 5/16/2001, the nurse at the health care facility evaluated the patient and noted that her extremities appeared bluish in color, her axillary temperature was 93.7, her blood pressure was 146/80, her pulse was 120, her respirations were 40, and her oxygen saturation on room air was 97%.  At 9:15 a.m., the patient’s pulse was 122, her axillary temperature was 94.1, and her oxygen saturation on room air was 84%.  The nurse re-evaluated the patient at 9:20 a.m. on 5/16/01 and her axillary temperature was 95.5, her pulse ranged between 88 and 100, her respirations were 28, and her oxygen saturation on room air was 94%.  The patient denied shortness of breath at that time and she did not appear to be cyanotic.  The nurse attempted to contact the patient’s family practitioner to update him on the patient’s condition.

The family practitioner contacted the health care facility by telephone at 10:00 a.m. on 5/16/2001 and the nurse updated him on the patient’s condition including her continuing nausea.  The family practitioner was not aware of and was not advised of the results of the CT scans of the chest and of the abdomen and pelvis.  The family practitioner gave an order for Compazine suppositories to be administered every 12 hours as needed.  This was the family practitioner’s last contact with the patient prior to her death at approximately 5:00 p.m. on 5/17/2001.  Another physician provided coverage for the family practitioner’s patient on 5/17/2001.

The family practitioner’s conduct in providing medical care for the patient fell below the minimum standards of competence in that he failed to order an abdominal series of x-rays to be obtained and interpreted prior to administering the oral contrast for the CT scan of the abdomen and pelvis.

The family practitioner’s conduct created the unacceptable risks that the patient may have been suffering from a perforation of the bowel or an obstruction of the bowel which may have contraindicated the administration of the oral contrast.  Oral contrast administered in the presence of a perforation of the bowel creates the unacceptable risks that the contrast will enter the abdominal cavity and cause inflammation of the abdominal cavity, additional discomfort for the patient, and complicate any potential medical procedures to treat the perforation of the bowel or any of the complications arising out of the perforation of the bowel.  Oral contrast administered in the presence of an incomplete or complete bowel obstruction creates the unacceptable risk of aspiration.

A minimally competent physician, to avoid or minimize the unacceptable risks to the patient, would have ordered an abdominal series of x-rays to assess the patient for a perforation of the bowel and for a bowel obstruction prior to administering the oral contrast for the CT scan of the abdomen and pelvis.

The Board ordered that the family practitioner pay the costs of the proceeding and complete 30 hours of continuing education in a gastroenterology review course, a significant portion of which will include instructions in the diagnosis and treatment of conditions of the gastrointestinal tract in the geriatric population.

State: Wisconsin


Date: July 2006


Specialty: Family Medicine, Internal Medicine


Symptom: Nausea Or Vomiting


Diagnosis: Acute Abdomen


Medical Error: Improper medication management, Failure to examine or evaluate patient properly, Failure to follow up


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Wisconsin – Family Medicine – Nausea, Vomiting, Diarrhea, Weakness, Poor Appetite, And Weight Loss



An 89-year-old female patient resided at a health care facility for the last two years.  The patient’s daughter had the health care power of attorney for the patient.  The patient had on file with the health care facility an advanced directive status of “do not resuscitate”.

Over the period from 4/30/2001 through 5/11/2001 the patient experienced symptoms of nausea, vomiting, loose stools, weakness, poor appetite and weight loss.  On 5/11/2001, the staff at the health care facility contacted the patient’s attending physician’s office and scheduled the patient for an appointment with the patient’s attending physician at his office on 5/11/2001.

On 5/11/2001, the patient’s attending physician examined the patient at his office and prescribed tetracycline for an infected ulcer on the patient’s right foot.  He also ordered metoclopramide for the patient’s nausea.  The patient returned to the health care facility following her appointment with her attending physician.

The patient continued to experience nausea, vomiting, and a poor appetite from 5/11/2001 through 5/14/2001.  On 5/14/2001, the patient’s attending physician was notified by the staff at the health care facility of the patient’s continuing nausea, vomiting, poor appetite, and weight loss.  The patient’s attending physician ordered a CT scan of the patient’s chest and a CT scan of the patient’s abdomen and pelvis to be performed with oral contrast only.  The patient’s attending physician also ordered a basic metabolic panel.

The specimen for the basic metabolic panel was collected at 2:25 p.m. on 5/14/2001 and the laboratory analysis and report were completed by 3:11 p.m. on 5/14/2001.  The laboratory report recorded as follows: Sodium 144 (136 – 145). Potassium 4.3 (3.5 – 5.0). Cl 104 (98 – 108) Carbon Dioxide 19.3 (24 – 32). Blood Urea Nitrogen 153 (7 – 18). Calcium 9.8 (8.8 – 10.5). Creatinine 4.4 (0.6 – 1.3). Glucose 114 (70 – 110).

The staff at the health care facility contacted the patient’s attending physician at 4 p.m. on 5/14/2001 and advised him of the laboratory values for the sodium, the blood urea nitrogen, and the creatinine.  The patient’s attending physician ordered that the diuretic the patient was taking be discontinued.

The CT scan of the patient’s chest was obtained on 5/14/2001 and the CT scan of the patient’s abdomen and pelvis were obtained on 5/15/2001.  The staff at the health care facility administered the first bottle of oral contrast for the CT scan of the abdomen and pelvis to the patient commencing at 6 a.m. on 5/15/2001 and administered the second bottle of oral contrast commencing at 7 a.m. on 5/15/2001.

On 5/16/2001, the radiologist read the CT scans of the patient’s chest and of the patient’s abdomen and pelvis.  He read the CT scan of the abdomen and pelvis as demonstrating a large amount of oral contrast accumulated within a dilated stomach and in the proximal small bowel consistent with an incomplete mechanical small bowel obstruction, marked distension of the urinary bladder, and diverticulosis of the descending and sigmoid colon.  The radiologist recommended placement of a nasogastric tube.  The radiologist dictated his radiology report making these findings and recommendations on 5/16/2001 and this radiology report was transcribed on 5/16/2001.

At 8:05 a.m. on 5/16/2001, the nurse at the health care facility evaluated the patient and noted that her extremities appeared bluish in color, her axillary temperature was 93.7, her blood pressure was 146/80, her pulse was 120, her respirations were 40, and her oxygen saturation on room air was 97%.  At 9:15 a.m., the patient’s pulse was 122, her axillary temperature was 94.1, and her oxygen saturation on room air was 84%.  The nurse re-evaluated the patient at 9:20 a.m. on 5/16/2001 and her axillary temperature was 95.5, her pulse ranged between 88 and 100, her respirations were 28, and her oxygen saturation on room air was 94%.  The patient denied shortness of breath at that time and she did not appear to be cyanotic.  The nurse attempted to contact the patient’s attending physician to update him on the patient’s condition.

The patient’s attending physician contacted the health care facility by telephone at 10:00 a.m. on 5/16/2001 and the nurse updated him on the patient’s condition including her continuing nausea.  The patient’s attending physician was not aware of and was not advised of the results of the CT scans of the chest and of the abdomen and pelvis.  The patient’s attending physician gave an order for Compazine suppositories to be administered every 12 hours as needed.

On 5/17/01, a family practitioner was providing coverage for the patient’s attending physician and was responsible for the patient’s medical care on 5/17/2001.  At 7:00 am on 5/17/2001, staff at the health care facility noted that the patient was poorly responsive with a blood pressure of 60/42, respirations of 18, and a pulse of 112.  After the patient was returned to bed, her blood pressure was 100/60.  The patient’s bowel sounds were quiet in all four quadrants.  At 9:30 a.m. on 5/17/2001, the patient remained poorly responsive but complained that her stomach hurt.  The nurse at the health care facility placed a telephone call to the family practitioner.  During this conversation, the nurse advised the family practitioner of the patient’s condition and informed him of the results of the CT scans, including the radiographic diagnoses of a distended bladder, a dilated stomach, and an incomplete mechanical small bowel obstruction.  The family practitioner ordered soap suds enemas and a clear liquid diet.  The patient was given two soap suds enemas resulting in a moderate amount of liquid stool.  The nurse was of the opinion that there was blood in the stool.  The patient remained poorly responsive.

At 2:30 p.m. on 5/17/2001, the staff at the health care facility contacted the family practitioner and updated him on the patient’s status and on the results of the soap suds enemas.  The family practitioner ordered that the soap suds enemas be repeated and that the patient be administered Dulcolax tablets.

The patient became progressively less responsive and at approximately 5:00 p.m. on 5/17/2001, the patient’s respirations and cardiac function ceased.  The family practitioner did not at any time between the time when he was notified of the results of the CT scan of the abdomen and pelvis and the time of the patient’s death consider providing treatment to the patient by inserting a nasogastric tube or recommend to or advise the patient, the daughter having the health care power of attorney, or any other member of the patient’s family of the option of inserting a nasogastric tube to decompress the patient’s stomach and thereby reduce the patient’s discomfort and reduce the risk of vomiting and aspiration.

The family practitioner’s conduct in providing medical care for the patient as set forth above fell below the minimum standards of competence accepted in the profession in that:

1)     The family practitioner, after being advised of the radiographic evidence of a distended stomach and an incomplete mechanical bowel obstruction, failed to consider providing treatment to the patient by inserting a nasogastric tube and failed to advise the patient, the patient’s daughter having the health care power of attorney, or any member of the patient’s family of the option of inserting a nasogastric tube to decompress the patient’s stomach and thereby reduce the patient’s discomfort and reduce the risk of vomiting and aspiration.

2)     The family practitioner ordered Dulcolax tablets for the patient when the use of this drug in oral tablet form was contraindicated by the incomplete mechanical small bowel obstruction.

The Board ordered that the family practitioner pay the costs of the proceeding, be reprimanded, complete 30 hours of continuing education in a gastroenterology review course, a significant portion of which will include instructions in the diagnosis and treatment of conditions of the gastrointestinal tract in the geriatric population.

State: Wisconsin


Date: July 2006


Specialty: Family Medicine, Internal Medicine


Symptom: Nausea Or Vomiting


Diagnosis: Acute Abdomen


Medical Error: Improper medication management, Diagnostic error, Failure of communication with patient or patient relations, Failure to follow up


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Wisconsin – Emergency Medicine – Chills, Headache, Weakness, Sore Throat, And Fever



A 20-year-old male was brought to the emergency department on 11/10/2002.  He complained of chills, headache, weakness, and fever of several hours duration, and cold symptoms, fatigue, and sore throat of several days duration.  At 11:50 a.m., his blood pressure was recorded at 134/57, heart rate at 109, respirations at 20, and temperature at 101.3.  Blood analysis of a sample drawn at 12:38 p.m. showed a white count of 5,700, 56% bands, 12% lymphocytes.  The manual analysis of the patient’s blood showed 30% neutrophils.

The ED physician examined the patient at 12:15 p.m. and had a throat culture and urinanlysis sample collected.  A rapid Strep test at approximately 12:30 p.m. was negative.  The ED physician’s record of the examination states that the patient denied neck pain, but that the patient said his neck was a little bit stiff.  The ED physician’s record of the examination states that the patient “does not really have any throat pain” although the patient said he could feel some swollen glands.  The ED physician’s physical examination found the patient’s neck to be “supple and non-tender.”

At 12:55 p.m., the patient was given 30 mg of Toradol for headache pain and the patient reported his headache was almost gone at 2:00 p.m.  At 1:00 p.m., the patient had a blood pressure of 115/50.  At 1:30 p.m., one liter of Lactated Ringers solution was administered to the patient as a flush; at 2:10 p.m., the nurse’s notes state that the flush was complete, and that the patient’s color was “a little more pink.”  His systolic blood pressure was recorded as 111, with no diastolic pressure recorded, heart rate at 110, and temperature at 102.2.

The ED physician suggested a spinal tap to the patient.  The parties disagree on the purpose for the tap.  The ED physician asserts that he sought the tap to evaluate the possibility of viral meningitis.  The complaint suggests the ED physician sought the tap on the possibility of bacterial meningitis.  The ED physician did not prescribe any antibiotics to the patient on the afternoon of 11/10/2002.

The patient was reluctant to consent to the spinal tap. The patient called his mother, who spoke with the ED physician.  The patient’s mother came to the hospital to discuss the situation with the patient and the ED physician.  The ED physician and the patient’s mother discussed a spinal tap.  The ED physician admitted the patient to the hospital, for observation and follow-up care of fever, headache, abdominal pain, and vomiting.

The initial nurse’s note for the patient at 2:50 p.m. records him saying “I’ve never felt this bad” and that his headache “is not so bad now” and describes the patient as very pale.  The nursing notes show the patient was feeling nauseous.  The patient told the nurse that he had stayed up late the previous night and woke up with the symptoms he was then experiencing.  The nursing notes indicate that the patient was oriented to place.

After discussion with the patient and his mother, the ED physician performed a lumbar puncture.  The puncture was performed at about 3:45 to 4:00 p.m.  The spinal fluid obtained was clear and colorless to the eye.  The cerebral spinal fluid was reported to contain one white blood cell and one red blood cell, the glucose was 64 mg/dl, the protein was 17 mg/dl and on gram stain analysis no organisms were seen.

At approximately 3:00 p.m., the nurse’s graphic record for the patient indicates a pulse of 104, respirations at 16, and blood pressure at 126/65.  At 4:00 p.m., the nurse’s note states “very pale; weak voice, very soft; lethargic” and records a temperature of 102.3˚ F.  The nurse’s graphic record indicates a pulse of 119, respirations at 16, blood pressure falling to 105/64.

The ED Physician was performing a spinal tap on the patient at this time and was able to observe the patient’s condition.

The ED Physician’s assessment of the Patient’s condition was that he did not have bacterial meningitis because the spinal fluid was clear and colorless. The ED Physician did not order antibiotics at the time of the lumbar puncture.

At 4:15 p.m., the patient was given 650 mg of Tylenol, and the nurse recorded that the initial laboratory result was negative for meningitis.  At approximately 6:30 p.m., the ED Physician assured the patient’s parents that the patient was comfortable, and needed fluids, but did not need to be transferred to another hospital.  The nurse’s notes for that time indicate that the patient had a temperature of 103.2, and that cold packs were placed at both axilla and on the forehead.  2 mg of morphine sulphate was administered for comfort at 7:00 p.m.

At approximately 8:30 p.m., the patient vomited, and the nurse noted that his color was still very pale, but that his lips now had a pink tinge.  The nurse’s graphic record for the period shows that the patient had a pulse of 109, respirations of 16, and blood pressures of 75/30, and 96/39 on another measurement about the same time.

At 10:10 p.m., the patient was found to have “wine stain” blotches over his entire body.  He was moved to an isolation room, and the ED Physician called an infectious disease consultant because the ED Physician suspected meningococcal disease.  At the suggestion of the infectious disease consultant and after consultation of the Sanford Guide, the ED Physician ordered the administration of Penicillin G, but none could be located in the hospital at the time. Instead, the ED Physician administered Ceftriaxone, 2 grams, IV, at 11:00 p.m.

The patient was noted to have a blood pressure of 86/56; normal saline was infused as a push to improve the blood pressure.  At 11:30 p.m., the patient was noted to be hypoxic.  The ED Physician ordered oxygen by nasal cannula at 2 liters/minute; the patient’s oxygen saturation was measured at 82% with the oxygen, and his blood pressure was measured at

113/73.  The ED Physician called for helicopter transport to another hospital.

At 11:45 p.m., the oxygen was increased to 3 liters/minute; the patient’s oxygen saturation increased to 84%, and his blood pressure was measured at 102/71.  The patient complained of “pain all over.”  At 11:50, the oxygen was increased to 5 liters/minute; the patient’s oxygen saturation decreased to 76%, and his blood pressure was measured at 110/72.

At 11:40 p.m., the patient was given 2 mg of morphine sulphate, IV.  At 12:10 a.m. on 11/11/2002, the patient began to repeatedly clear his throat.  The ED Physician examined him, and saw “significant hemorrhaging occurring back by the tonsils and posterior pharyngeal area.” The ED Physician called for anesthesia assistance for intubation to protect the patient’s airway.

At or about 12:30 a.m., the patient began to cough and stated that his chest “feels like it is filling up.”  On auscultation, the patient’s lungs were congested throughout.  At 12:30 a.m., the patient began to cough up frothy pink fluid.

At 12:45 a.m., the patient lay down, became “less responsive” and the ED Physician began to suction the patient’s airway and attempted intubation.  At 12:50 a.m., a Code Blue was initiated.  The patient was intubated by a CRNA, and suctioned for large amounts of red frothy fluid.  Resuscitation efforts continued until the ED Physician declared the patient dead at 1:06 a.m.

The complaint against the ED physician alleged that the ED Physician’s conduct was below the minimum standard of competence given failure to administer antibiotics to treat suspected bacterial meningitis at or before the time of hospitalization in that such treatment would have been the appropriate treatment for the disease the patient actually had, meningococcemia.  It was alleged the patient presented with symptoms for which the differential diagnosis should have included viral meningitis, sepsis, and bacterial meningitis.

After the investigation, the Board found there was no probable cause to believe the ED physician was guilty of unprofessional conduct or negligence in treatment and ordered that any disciplinary action against the ED physician be dismissed.  The validity that a suspicion of viral meningitis mandated an equal suspicion of bacterial meningitis was disputed.  The ED Physician testified the lack of classical symptoms in the patient’s presenting symptoms indicated bacterial meningitis did not need to be in the differential diagnosis: no stiff neck, no altered mental status, and no focal problems.  It was also not reasonably certain that the amounts of antibiotics that would have been administered for the treatment of suspected bacterial meningitis between 2:30 p.m. and 4:00 p.m. would have had any beneficial effect to the patient.

State: Wisconsin


Date: August 2005


Specialty: Emergency Medicine


Symptom: Nausea Or Vomiting, Fever, Headache


Diagnosis: Meningitis/Encephalitis


Medical Error: False negative


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Wisconsin – Emergency Medicine – Fever, Elevated WBC, And Abdominal Pain Diagnosed As Possible Mittelschmerz



On 7/8/1999, a 13-year-old patient presented to an urgent care clinic at a hospital complaining of back pain, right lower quadrant abdominal pain, and with a fever of 101 degrees.  The patient was five feet tall and weighed 265 pounds.  The nurse’s examination notes state that the patient’s abdomen was round and firm, and that it was soft.  A family practitioner assessed the patient’s abdomen as soft with positive bowel sounds and lower right quadrant tenderness.  The family practitioner noted in the patient’s chart that her pulse rate was 120 per minute, and that her respirations were 32 per minute.

The family practitioner ordered laboratory analysis of a blood sample.  In his documentation, the family practitioner stated “[w]hite count is bizarre with a 5700 white count, 24 neutrophils, 32 bands.  Reactive lymphs are increased.”  The family practitioner ordered two radiographs, a flat plate, and an upright, which he read as “basically unremarkable”.  Three radiographs were taken of the patient. The family practitioner did not learn that the third x-ray film had been taken until sometime after that day.

The x-ray films taken of the patient were read the next day by a radiologist, who noted free air in the abdomen.  The radiologist noted the following in his report: “Impression: Findings consistent with free air under both diaphragms with several associated slightly distended loops of small bowel.  These findings were called immediately to the Treatment Center and discussed with [a physician].”

The family practitioner prescribed Toradol 60 mg IM, for pain, and assessed the patient’s condition as “Probable Mittelschmerz.”  Mittelschmerz is a condition of pain on ovulation; it lasts approximately six to eight hours, and is not accompanied by any notable fever, or by rapid pulse or respirations, or an increase in immature white blood cells in circulation.  The patient’s temperature, band count, pulse rate, and respiration rate were all significantly elevated.  An internal pelvic examination, pelvic ultrasound, or CAT scan was not performed when the patient presented at urgent care.

Prior to releasing the patient to go home, the family practitioner consulted with a surgeon regarding the patient’s symptoms and health status.  The family practitioner did not determine that the patient had free air in her abdomen and, therefore, did not inform the surgeon of its presence.  The family practitioner did not ask surgeon to come to the hospital to examine the patient, or to come to the hospital to examine the radiographs of the patient.  A minimally competent family practice physician would call a surgeon to the hospital to examine the patient and keep the patient in the hospital under close observation when free air is observed in an abdominal radiograph.

The family practitioner released the patient to go home with her mother, with instructions to contact the surgeon if her condition got worse overnight; finish taking her Macrobid; to consume “clear liquids tonight only”; to return to the clinic the following morning to undergo another complete blood count (CBC), and, if not better, to see the surgeon the following day.  The family practitioner also prescribed Naprosyn 500 bid for pain.

The family practitioner’s decision to send the patient home with a diagnosis of Mittelschmerz exposed her to the grave risk of an untreated surgical emergency, when the minimally competent physician would have begun prompt medical intervention and preparations for surgery.

The family practitioner noted the following in the patient’s chart:

SUBJECTIVE: This is a 13-year-old white female, very heavy 265 pounds with temperature 101 today.  Seen and put on Microbid and Pyridium Saturday for UTI.  Continues to have back pain and fever, right lower quadrant pain today, mucousy stool, usually is soft, a little harder today.

OBJECTIVE: Temperature 101, went down with Tylenol.  Pulse 120, respiratory rate 32.  Head: Normocephalic, atraumatic.  Eyes: PERRLA.  Tympanic membranes intact. Abdomen is soft.  Positive bowel sounds.  Right lower quadrant tenderness. She is two weeks post-period.  White count is bizarre with a 5700 white count, 24 neutrophils, 32 bands.  Reactive lymphs are increased.  Flat plate and upright are basically unremarkable.

ASSESSMENT: Probable mittelschmerz. She got excellent relief with Toradol in the treatment center and was able to hold down some Sprite.

PLAN: Naprosyn 500 bid, finish her Macrobid.  Clear liquids tonight only.  If any worsening tomorrow, mom is a nurse on 2 South, she will see [the surgeon] in the morning. I discussed the case with him and he said to watch it tonight and he will deal with it tomorrow if there is any increase in pain.

While at home, the patient vomited throughout the night and aspirated.  She was brought to the urgent care clinic the next morning, with cold and mottled skin, shallow panting respirations, and mental confusion.  She required resuscitation in the urgent care, and was taken directly to the operating room. The surgeon’s impression was: “septic shock, probably due to perforated viscus”.

The operation disclosed a tubo-ovarian abscess with large quantities of pus in the intraperitoneal cavity. The patient suffered two cardiac arrests during the operation, from which she was resuscitated, and two episodes of bradycardia, with resuscitation. She was taken to the intensive care unit with adult respiratory distress syndrome, renal failure, hemodynamic instability, and died early the next morning from cardiac arrest with ventricular fibrillation that could not be corrected.

The patient’s discharge summary report dictated after the operation stated the following regarding the patient’s diagnosis: Preoperative diagnosis: ABD Pain.  Final Diagnosis: 1) marked chronic salpingitis with fibrosis; 2) ovarian abscesses with acute fibrinopurulent peritonitis change.

The Board ordered the family practitioner pay the costs of the proceeding, be reprimanded, and complete 24 hours of continuing education in abdominal diagnosis, evaluation and management, including pediatric or adolescent patients.

State: Wisconsin


Date: August 2005


Specialty: Emergency Medicine, Family Medicine, Gynecology, Internal Medicine, Pediatrics


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


Diagnosis: Acute Abdomen, Sepsis


Medical Error: Diagnostic error


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 5


Link to Original Case File: Download PDF



Wisconsin – Emergency Medicine – 4-Year-Old Infant With Diarrhea, Fever, And Persistent Vomiting



On 11/25/1996, 4-year-old infant was taken to his primary pediatrician for a routine checkup and immunizations.  The patient had had a cold and stuffy nose for a couple of days and was more fussy than usual.  The pediatrician’s examination disclosed that the patient was afebrile, his lungs were clear, and his abdomen was soft and nontender with positive bowel sounds.  The pediatrician diagnosed a viral syndrome and elected to delay administering the immunizations.  The patient remained fussy on 11/26/1996.

On 11/27/1996, following the patient’s afternoon nap, the patient’s mother noted two small spots of blood in his stool when she changed his diaper.  He also had developed diarrhea.  When she attempted to feed him, he vomited and continued to vomit with each attempt to feed him thereafter.  He continued to have diarrhea.  He became more fussy as the day went on with more crying episodes and he became more difficult to console.

On the evening of 11/27/1996, the patient’s mother contacted the emergency department at the hospital.  The emergency department referred her to the pediatrician on call and she spoke with him by telephone at approximately 9:00 p.m. on 11/27/1996.  She reported the patient’s symptoms to her pediatrician and also reported that the patient had a low grade fever.  The pediatrician recommended that she give Tylenol and that she spoon feed Pedialyte every 15 minutes.

The patient remained fussy throughout the night of 11/27/1996 – 11/28/1996 and continued to vomit.  The patient remained fussy and continued to cry and to vomit on the morning of 11/28/1996.  At 4:43 p.m. on 11/28/1996, the patient’s mother and father took him to the emergency department at the hospital with continuing complaints of vomiting, diarrhea, and fever.

The emergency department nurse obtained a medical history from the patient’s mother.  The patient’s mother reported that the patient was fussy and had had diarrhea for 2 days with 4 to 5 watery diarrhea stools the prior day but no incidents of diarrhea on the day of the emergency department visit.  The patient’s mother noted that the patient’s diarrhea had been brownish-reddish in color and the nurse observed a small amount of the brownish-reddish diarrhea in the patient’s diaper at the time of his admission to the emergency department.  The patient’s mother also reported that the patient had begun vomiting the prior day and was continuing to vomit with 3 episodes of vomiting earlier on the day of the emergency department visit.  The patient’s mother reported that the patient had had a fever the previous evening.  The nurse noted that the patient was awake, active, alert, and smiling when she assessed him in the emergency department.  The nurse’s assessment disclosed that the patient’s lungs were equal and clear bilaterally and he had bowel sounds in all 4 quadrants.

The ED Physician obtained a medical history from the patient’s mother and spoke with the emergency department nurse about her findings.  The ED Physician ascertained from the patient’s mother that the patient began to develop loose stools on 11/25/1996, but did not have diarrhea.  On 11/26/1996 and 11/27/1996, the patient had diarrhea with 5 stools on 11/27/1996 and 1 stool on 11/28/1996 prior to the patient’s arrival in the emergency department.  The ED Physician was told by the patient’s mother that the patient’s stool might have blood in it.  The ED Physician also ascertained from the patient’s mother that the patient had been vomiting since 3:00 p.m. on 11/27/1996 and had vomited at least 6 times on 11/27/96 and 3 times since awakening on 11/28/1996.  The ED Physician was told by the patient’s mother that she had been giving Tylenol every 4 hours to control the patient’s fever.

The ED Physician examined the patient in the emergency department on 11/28/96.  The ED Physician’s differential diagnosis was gastroenteritis, intussusception, [appendix], Meckel’s diverticulum, pyloric stenosis, and a secondary diagnosis of dehydration.  The differential diagnosis did not include an inguinal hernia.

The ED Physician conducted the examination while the patient was being held supine on his mother’s lap, not positioned on an examining table.  She did not listen for the patient’s bowel sounds.  She did not perform a visual inspection of the patient’s rectal area.  She did not perform a visual inspection the patient’s inguinal area.  She visualized the patient’s abdomen during her examination.  She palpated the patient’s abdomen with hand to patient skin contact during her examination.

The ED Physician noted that at the time of the examination, the patient was interactive, sleepy, and in no acute distress.  The ED Physician recorded in the emergency department record that the patient’s lungs were clear with good aeration and his abdomen was soft and nontender without masses.  The ED Physician observed reddish-brown stool in the patient’s diaper but noted no frank blood.  The ED Physician was of the opinion that the stool in the diaper did have blood in it, but she saw no indication that it had a currant-jelly appearance.  The ED Physician also examined the patient’s fontanel, the membranes of the patient’s mouth and lips, and the patient’s eyes for evidence of dehydration. The ED Physician also noted that the patient had tears. The ED Physician concluded that the patient was not dehydrated.

The ED Physician’s diagnosis in the emergency department on 11/28/1996 was viral gastroenteritis.  She recommended that the patient return home and remain on clear liquids for 24 hours and then be given % strength formula for the next 24 hours and then return to full strength formula as tolerated.  The ED Physician also recommended that the patient’s mother follow up with the patient’s regular pediatrician the following morning.  The ED Physician told the patient’s parents to return to the emergency department if the patient’s condition worsened or if the patient developed signs of dehydration.

On the night of 11/28/1996 – 11/29/1996, the patient slept for brief periods of time but frequently woke up crying. At approximately 6:30 a.m. on 11/29/1996, the patient’s mother observed some brown foul smelling emesis trickling out of the side of the patient’s mouth.  The patient’s mother determined that they should take the patient back to the emergency department.  While she was changing the patient’s clothes, she noted that the patient was breathing abnormally and his eyes were fixed straight ahead.  While in the car on the way to the emergency department, the patient stopped breathing.  Attempts at resuscitation at the emergency department at the hospital were unsuccessful.  The patient was pronounced dead at 7:14 a.m. on 11/29/1996.

An autopsy was performed at 11:00 a.m. on 11/29/96, which disclosed intussusception with 4.5 centimeters of the ileum telescoped into the cecum.  The entire wall of the telescoped terminal ileum and cecum were markedly dark, edematous, and friable; consistent with ischemia. The patient’s lungs were markedly congested and other organs showed generalized congestion. A blood culture taken from the right ventricle of the patient’s heart grew Enterococcus faecalis.

The allegation against the ED Physician was not a failure to diagnose, but a failure to do a competent examination. After an investigation, the Board determined the ED physician’s assessment of the patient’s medical condition as set forth above met the minimum standards of competence accepted in the profession and did not create an unacceptable risk to the patient in the following respects:

1) The ED Physician performed a minimally competent abdominal examination.

2) The ED Physician was not required to listen for bowel sound, because in the absence of any tenderness upon palpation of the abdomen, the presence or absence of bowel sounds and their quality would mean little in differentiating between diagnoses, especially owing to the fact that the patient recently had had a bowel movement.

3) The ED Physician was not required to perform a rectal evaluation in this instance given the patient’s history and presenting symptoms.

4) The ED Physician was not required to visualize the patient’s inguinal area because an inguinal hernia was not a part of her differential diagnosis and the Board stipulated that she was not subject to discipline based upon a failure to diagnose, or based upon a failure to create a minimally competent differential diagnosis.

The Board ordered that the disciplinary action against the ED physician be dismissed.

State: Wisconsin


Date: December 2004


Specialty: Emergency Medicine, Pediatrics


Symptom: Fever, Blood in Stool, Diarrhea, Nausea Or Vomiting


Diagnosis: Acute Abdomen


Medical Error: No error found


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Wisconsin – Internal Medicine – Patient With Probable Upper GI Bleed Elects To Delay Endoscopy Due To Costs



An internist cared for a female patient born in 1950, beginning in 1993.  The patient had duodenal ulcer disease since at least 1993, and was being treated medically with ranitidine.  The patient had a stressful home situation and was a tobacco smoker.

On 7/16/1997, the patient presented for the first time in over two years.  She reported feeling “terrible” and unable to keep food down other than a little sweetened milk.  She had a blood pressure of 150/80 and a normal temperature.  The internist charted that she reported having “coffee ground emesis” three times, epigastric pain with some tenderness in the epigastrium without masses or rebound, and a hemoglobin of 10.1, representing a decrease from 12.3 some three years before.

The internist’s chart states that his diagnosis is “probably PUD [peptic ulcer disease] with mild anemia secondary to UGI [upper gastrointestinal] blood loss.”  He scheduled her for a UGI series (x-rays) and started her on omeprazole 20 mg.  The internist’s chart entry further recites that the patient had no health insurance and therefore she wanted to delay UGI endoscopy if at all possible.

A reasonable internist, confronted with the same or similar circumstances, would have ordered an immediate endoscopy to determine the cause of the probable upper-GI bleed, which could have been done on an outpatient basis.  The patient died on 7/25/1997, as a result of internal hemorrhage from a gastric ulcer. The patient’s condition was life-threatening, which endoscopy would have revealed and which could have been treated.  To the extent that the patient declined endoscopy, the chart does not reflect that the patient was fully informed of the seriousness of her condition.

The Board ordered that the internist pay the costs of the proceeding, be reprimanded, complete 8 hours of continuing education in the elements of patient informed consent, and complete 8 hours of continuing education in the proper diagnosis, care and treatment of upper gastrointestinal disease, which shall include recognizing and appropriately responding to complications of ulcers.

State: Wisconsin


Date: February 2004


Specialty: Internal Medicine, Family Medicine, Gastroenterology


Symptom: Nausea Or Vomiting, Abdominal Pain


Diagnosis: Hemorrhage, Gastrointestinal Disease


Medical Error: Failure to order appropriate diagnostic test


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



California – Family Practice – Home Visit Evaluation Of Stomach Cramps, Nausea, Vomiting, And Diarrhea Diagnosed As Pulled Muscle



On 12/26/1997, a patient became ill with stomach cramps, nausea, and subsequent abdominal pain, vomiting, and diarrhea.  On 12/30/1997, the family practitioner went to see the patient at her home.  In his examination of the patient, the family practitioner pressed on the patient’s stomach and took a urine sample.  The family practitioner told the patient that there was no blood in her urine.  He also told the patient that her pain was caused by a muscle pulled during coughing.

In the patient’s chart note for that visit, there was no indication that the family practitioner took the patient’s temperature or that he performed a history and physical.  The chart note indicates that the patient had abdominal muscle pain with acute gastroenteritis.

On 1/1/1998, the patient presented to an emergency department.  The record prepared by the emergency department physician indicated that the patient presented with complaints of abdominal cramps, nausea, vomiting, and diarrhea for the prior three days.  The ED physician’s assessment of the patient indicated abdominal pain etiology to be determined, questionable early appendicitis versus other intra-abdominal pathology, dehydration, electrolyte imbalance, hyponatremia, and hypokalemia.  In the records, the ED physician further noted that the family practitioner was aware of the patient’s condition, and the ED physician had fully discussed the case and the patient’s disposition with the family practitioner.  The ED physician ordered x-rays and laboratory tests.  Laboratory tests reviewed a WBC of 15.2 with a marked left shift (24% bands and 69% polymorphonuclear cells).  The patient was discharged.

On 1/2/1998, the patient’s husband contacted the family practitioner with complaints from the patient of black stools.  The family practitioner advised the husband to bring in the patient’s stool specimen.  The stool sample was tested and found to be negative for occult blood.  The family practitioner did not ask the husband to bring in the patient.  The family practitioner did not re-examine the patient.  The family practitioner did not obtain any of the patient’s emergency department records.

On 1/8/1998, the patient’s husband telephoned the family practitioner.  On 1/10/1998, the family practitioner returned the telephone call.  The patient’s husband told the family practitioner that the patient was taking the medication clarithromycin, an antibiotic which had been prescribed for a family member.  The patient requested this medication be refilled for herself since it seemed to be helping her.  The family practitioner agreed to fill a prescription for clarithromycin for her.  The family practitioner was informed that, at this time, which was day 14 of the patient’s illness, the patient was still very sick and could hardly get out of bed.

On 1/14/1998, the patient was admitted to the hospital by another physician.  The patient had continuing complaints of fever, nonproductive cough, and abdominal pains.  The physician’s assessment of the patient was a probable appendiceal abscess, history of mild asthma, and history of urethral stricture status post dilation.

On 1/15/1998, surgery was performed. The surgery revealed that the patient had a perforated appendix with multiple pelvic abscesses.  Surgeons removed the terminal ileum, cecum, and ascending colon with side-to-side anastomoses of the ileum and transverse colon.

The patient continues to suffer profound debility, bowel urgency, and diarrhea secondary to short colon.  The patient has required monthly vitamin B-12 injections secondary to removal of the terminal ileum.

The Board judged the family practitioner’s conduct as having fallen  below the standard of care given the following reasons:

1) When the family practitioner made a house call in 12/1997, he failed to perform an adequate physical examination of the patient.

2) He failed to take the patient’s temperature and failed to perform a pelvic and rectal examination.

3) He failed to prepare adequate chart notes of his examination of the patient.

4) He failed to order laboratory tests.

5) He failed to obtain and review the patient’s medical records from her visit to the emergency department on 1/1/1998.

6) He failed to recognize the significance of the laboratory tests obtained in the emergency department.

7) At the request of the patient, the family practitioner refilled clarithromycin for the patient despite his initial diagnosis of “gastroenteritis.”

8) The family practitioner failed to recognize that 14 days of illness was too long for gastroenteritis and failed to consider alternative diagnoses.

9) He failed to diagnose and timely treat appendicitis.

10) He failed to understand that appendicitis can present in a variety of ways.

11) He failed to recognize that retrocecal appendicitis may present with diarrhea.

12) He failed to consider further examination when he was informed of the patient’s significant debility and worsening condition.

The Board deemed the family practitioner’s conduct as having fallen below the standard of care and placed the family practitioner on probation for two years.  Stipulations included enrolling in the Physician Assessment and Clinical Education Program at the University of California, San Diego School of Medicine (“PACE Program”), completing a medical record keeping course, completing 16 hours of continuing medical education in the area of deficiency, submitting quarterly reports, and paying a fine.

State: California


Date: June 2002


Specialty: Family Medicine, Emergency Medicine, Hospitalist, Internal Medicine


Symptom: Abdominal Pain, Diarrhea, Nausea Or Vomiting


Diagnosis: Acute Abdomen


Medical Error: Failure to examine or evaluate patient properly, Underestimation of likelihood or severity, Lack of proper documentation


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


Case Rating: 4


Link to Original Case File: Download PDF



Virginia – Internal Medicine – Chronic Renal Failure, Weight Loss, On Digoxin With Gram-Positive Bacteremia



On 4/8/1998, a 72-year-old female with a history of atherosclerotic cardiovascular disease, congestive heart failure, and chronic renal failure, with complaints of nausea and vomiting, weight loss, and inability to eat.  The patient was dehydrated on admission.

On 4/9/1998, the patient’s blood culture showed gram-positive cocci, for which imipenem was ordered at 1 gm every 8 hours.  The patient’s digoxin level was reported at 3.3, and the digoxin was held.

On 4/10/1998, the patient had evidence of a seizure.  CT scan of the head revealed no acute abnormalities to explain the seizure.  The patient was transferred to the ICU.  Imipenem was discontinued.

On 4/13/19998, the digoxin was reinstituted without any recheck of the level.

The informal Conference Committee (“Committee”), composed of three members of the Board, expressed concern that the imipenem dose was inappropriately high (renal function not reported).  There were also concerns that the digoxin level was restarted without rechecking the level.

After a careful review of the records of his care regarding multiple patients and other information provided, and following a discussion with the nephrologist, the Committee found that he had no violations.  The physician provided evidence that in July 1999 after a six-month review of his medical records found no deficiencies, he was granted full staff privileges at a hospital.  Based on the foregoing, the Committee voted unanimously to dismiss this matter with no action.

State: Virginia


Date: June 1999


Specialty: Internal Medicine


Symptom: Nausea Or Vomiting, Weight Loss


Diagnosis: Neurological Disease, Renal Disease


Medical Error: No error found


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Wisconsin – Family Practice – Pseudoephedrine For Dizziness, Plugged Ears, Nausea, And Difficulty Walking



On 06/11/1980, a patient presented to a family practitioner with dizziness, plugged ears, nausea, and difficulty walking.  The family practitioner did not document the patient’s medical history and his family history.  He did not conduct a physical examination of the patient other than his ears.  The family practitioner flushed the patient’s right ear canal, but did not document the results.  The family practitioner did not take his blood pressure.  He did not conduct further studies or order any lab tests.  He prescribed pseudoephedrine.  There was no plan for a follow-up.

The patient worsened, developed slurred speech, began favoring his left hand over his right hand (despite being right-handed), and had even more difficulty walking.

On 06/14/1980, the patient’s wife called the family practitioner’s office, given that the patient had not improved.  The family practitioner was not in the office that day.  The family practitioner’s partner told the patient’s wife to bring the patient to the emergency department.

On 06/14/1980, the patient presented to the emergency department.  At 11 a.m., his blood pressure was 250/178.  At 11:20 a.m., his blood pressure had increased to 290/190.

On 07/07/1980 despite continued medical treatment, the patient eventually succumbed to his illness and died.  The final pathologic diagnoses included thrombosis of bilateral vertebral arteries with infarction of the right cerebellum and thrombosis of the right coronary artery.  The patient had been treated for hypertension in 1971 and 1972, but was not taking any medication for hypertension when he was treated by the family practitioner in 1980.

The Board judged the family practitioner’s conduct to be below the standard of care given failure to check the patient’s blood pressure prior to administering pseudoephedrine and failure to diagnose cerebellar stroke in a patient with difficulty walking.

He was ordered to complete a continuing medical education in neuroanatomy and neurophysiology at the University of Wisconsin Medical School.  He was ordered to adopt office procedures to ensure every patient of his has a medical history taken and an appropriate physical examination documented.  A reviewing physician was to be monitoring the family practitioner and reviewing his medical records every three months to ensure compliance.  The reviewing physician was to submit written reports.

State: Wisconsin


Date: March 1989


Specialty: Family Medicine, Internal Medicine, Neurology


Symptom: Dizziness, Nausea Or Vomiting


Diagnosis: Ischemic Stroke, Acute Myocardial Infarction


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


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Page 11 of 11