Found 109 Results Sorted by Case Date
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Florida – Plastic Surgery – Liposuction Performed On A Patient With Obesity, Diabetes, Hypertension, Asthma, And Human Immunodeficiency Virus



On 1/11/2013, a 50-year-old male presented to a plastic surgeon and underwent liposuction of his chin, upper abdomen, lower abdomen, upper back, and lower back/flanks.

The patient’s medical history included obesity, diabetes, hypertension, asthma, and human immunodeficiency virus (HIV) positive status.

Due to his medical history, the patient was at high risk of complications from the liposuction procedure.

Due to the high risk of complications, the patient was not a candidate for liposuction surgery.

During the liposuction procedure, the plastic surgeon injected tumescent wetting solution into the patient.  The tumescent liposuction technique, as opposed to “dry liposuction,” involves injection of tumescent wetting solution into a patient’s fatty deposits to reduce the amount of blood lost during the procedure.

The standard concentration of tumescent wetting solution used for liposuction is approximately one part epinephrine per 1 million units.  The tumescent wetting solution that the patient injected into the patient did not contain any epinephrine.

During the liposuction procedure, the plastic surgeon perforated the patient’s abdominal cavity and bowel.

On 1/16/2013, the patient presented to the medical center emergency department with complaints of abdominal pain, nausea, and vomiting.

Evaluation revealed that the patient was septic, in acute renal failure, and had free air in his abdomen.

The patient underwent emergent exploratory laparotomy which revealed multiple small bowel perforations, peritonitis, a mesenteric tear, pelvic abscess, and necrotizing fasciitis on the anterior abdominal wall.

The patient underwent release of a small bowel obstruction, small bowel resection, repair of the mesenteric defect, drainage of the pelvic abscess, and radical debridement of the necrotizing fasciitis.

The Medical Board of Florida judged that the plastic surgeon failed to avoid performing the liposuction procedure due to the high risk of complications posed by his medical history.  He failed to use epinephrine in the tumescent wetting solution used for the liposuction procedure.  He also failed to avoid perforating the abdominal cavity and bowel.

The Medical Board of Florida issued a letter of concern against the plastic surgeon’s license.  The Medical Board of Florida ordered that the plastic surgeon pay a fine of $5,000 against his license and pay reimbursement costs for the case at a minimum of $3,090.60 but not to exceed $5,090.60.  The Medical Board of Florida also ordered that the plastic surgeon complete five hours of continuing medical education in the area of “Tumescent Liposuction” and five hours of continuing medical education in “risk management.”

State: Florida


Date: May 2017


Specialty: Plastic Surgery


Symptom: Abdominal Pain, Nausea Or Vomiting


Diagnosis: Procedural Site Infection, Acute Abdomen, Necrotizing Fasciitis, Post-operative/Operative Complication


Medical Error: Unnecessary or excessive treatment or surgery, Improper medication management, Procedural error


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – General Surgery – Nausea, Vomiting, And Diarrhea After Fissurectomy, Hemorrhoidectomy, And Sphincterotomy



A patient was referred to a general surgeon specialized in colorectal surgery by his primary care doctor.  The patient presented to the general surgeon on 4/10/2012 as a 35 year-old-man with anal pain since age 16.

The patient’s medical history included a 12/30/2003 colonoscopy with biopsies by a gastroenterologist, who made a postoperative diagnosis of anal fissure, rectal polyp, and two small sigmoid polyps.  The biopsies revealed benign hyperplastic polyps.  In 2009, the patient had a lumbar discectomy at L4-L5.  In October 2011, the patient was referred to, and seen by, a cardiologist.  The cardiologist found “no evidence of any fixed coronary arterial disease in the left dominant system…elevated resting left ventricular end-diastolic pressure suggests left ventricular diastolic non-compliance likely due to history of hypertension and obesity.”  In sum, the patient presented to the general surgeon with morbid obesity, hypertension, dyslipidemia, post-two back surgeries, with a resulting DVT, cardiac complaints, and a list of prescription medications; and a social history including a one pack per day smoking habit, cannabis use, and occasional alcohol use.

The patient appeared with his wife for his appointment with the general surgeon.  The patient was given a two-page medical questionnaire to complete.  The patient filled in page one of the questionnaire and the patient signed page two, leaving blank the box on page two asking the patient to circle symptoms applicable to their current condition (e.g., headaches, shortness of breath, chest pains, blood in stool, etc.).  The patient was called out of the lobby by a medical assistant, who took his vital signs and questioned him about the information listed on the questionnaire.  The medical assistant learned that the patient was allergic to penicillin, which the patient had not listed on the questionnaire.  The medical assistant reported that the patient’s vital signs to the general surgeon on a yellow sticky note was as follows: “Temp-98.2 F, Weight-341 lbs., Height-72 in., BP [Blood Pressure]-139/77, Pulse-84, RR[Respiratory Rate]-21, BMI [Body Mass Index]-46.3.”

The medical assistant then escorted the patient to an examination room. The general surgeon entered and spoke to the patient. The general surgeon took notes by hand, indicating the following:

“hemorrhoids three times after laminectomy[1l in January; symptoms greatly increased over the last six months; Bowel Habits-small stools, tenesmus [urge to defecate, but cannot], and mucus discharge; hiatal hernia; colonoscopy negative; History of polyps; no sigmoidoscopy.”

The general surgeon and the medical assistant created the chart note for the patient’s visit, which reports out the following:

CC [Current Complaint]: Hemorrhoids

HPI [History of Present Illness]: The patient is a pleasant 35- year-old referred here by [his primary care physician]. He is here because of a 3-year history of hemorrhoids with progressive painful BM’s [bowel movements], tenesmus, BRBPR [bright red blood per rectum], and small stools last 6 months. Known history of fissure. Last colonoscopy negative.

ROS [Review of Systems]: General-denies fever, night sweats, weight loss; Neurological-denies loc [loss of consciousness], ha [headaches], diplopia [double vision], tinnitus [ringing in the ears], vertigo [dizziness], numbness, tingling, incoordination; Respiratory-denies sob [shortness of breath], wheezing, coughing, hemoptysis [coughing up blood]; CV [cardiovascular system ]-denies angina, palpitation, leg cramps, pedal edema, pnd [ difficulty breathing], nocturia [ excessive urination at night], orthopmea [shortness of breath while lying down], claudication [cramping leg pain caused by exercise]; GI [gastrointestinal system]-denies nausea, vomiting, hematochezia [fresh blood in stool], hematemesis [vomiting blood], jaundice, diarrhea, incontinence, heartburn, indigestion, dysphagia [difficulty swallowing], poor appetite, constipation; GU [genitourinary]-denies dysuria [painful urination], hematuria [blood in urine], incontinence, impotence, pneumaturia [passage of gas with urine], fecuria [fecal matter in the urine]; MS [musculoskeletal]-denies stiffness, arthralgia joint pain], weakness, atrophy, bone pain, Raynaud’s [severe blood flow reaction to blood vessels in the cold in fingers and toes]; Endocrine-denies heat intolerance, cold intolerance, dry skin, dry hair, hoarseness, polydipsia [abnormally large thirst], polyuria [production of abnormally large levels of diluted urine]; Hematologic-denies bleeding, bruising, ecchymosis [discoloration of the skin resulting from bleeding underneath], pk [Pyruvate kinase deficiency, one of the most common enzymatic defects of the erythrocyte].

PMH [Past medical history]: Medical-hypertension, dyslipidemia [high cholesterol]; Surgical-lumbar laminectomy, micro-discectomy.

SH [Social history]: Patient denies recreational drug use; Smokes 1 pack/day for 15 years; Occasional alcohol consumption.

FH [Family history]: Mother- 69 alive with hypertension [high blood pressure]; Father-DEC [deceased] at 65 heart attack; Siblings- 1 brother alive at 41 with CVD [cardiovascular disease], 2 sisters alive, 1 with diabetes another with CVD.

Allergies: Penicillin.

Meds:

acetaminophen-hydrocodone 325 mg.-7.5 mg. [Norco] oral tablet, folic acid 1 mg oral tablet, Xanax XR 0.5 mg oral tablet, extended release, zolpidem [ Ambien] 10 mg oral tablet.

Vitals: T [temperature]-98.2 F, Wt [weight]-341 lbs., Ht [height]-72 in., BP [Blood Pressure]-139/77, P [pulse]-84, RR [Respiratory Rate]-21, BMI [Body Mass Index]-46.3.

PE [Physical examination]: General-WD/WN [well­-developed/well-nourished] in NAD [no abnormality detected]; HEENT[head, eyes, ears, nose, throat]-PERRLA [Pupils equal, round & reactive to light & accommodation], EOMl, [extraocular movements intact], ENT [ear, nose, throat] wnl [within normal limits]; Neck-not thyromegally [enlargement of the thyroid gland] or masses, no ND [jugular venous distension] or bruits [a systolic murmur heard in the neck]; Chest-clear to auscultation and percussion; Cardiac-no murmur or gallop; Abdomen-no masses or organomegaly [enlargement of the viscera], non-tender; Extremities-no clubbing, cyanosis or edema, full range of motion; Neuro-grossly intact; Anorectal­: inspection showed posterior fissure, with spasm, no further exam. Large skin tag RPQ [right posterior quadrant]. Cannot rule out hemorrhoids.

A/P [assessment/plan]:

#ANAL fissure (565.0);

#HYPERLIPIDEMIA OT/UNSPEC (272.4);

#HYPERTENSION UNSPEC (401.9).

Fissurectomy, lateral sphincterotomy, possible hemorrhoidectomy. The risks, benefits, and alternatives, including the slight chance of incontinence, are discussed.

Following the examination, the patient signed two information and consent forms: Hemorrhoids-Surgical Hemorrhoidectomy and Anal Fissure-Fissurectomy and Sphincterotomy.

No surgery was scheduled, and the patient left the general surgeon’s office. The general surgeon did not request the patient’s medical file from the primary care doctor.

On 4/23/2014, at approximately 9:00 a.m., the patient called the general surgeon’s office, complaining of terrible pain and pleading for relief. At the time, the general surgeon was in surgery at a surgery center. The general surgeon was contacted in the operating room (OR) by his office on behalf of the patient. Although the general surgeon was scheduled for a full day of surgeries, he offered to operate on the patient at the end of his surgical schedule that day. The patient accepted. The general surgeon’s office transmitted a Pre-Admission form, with Physician’s Orders, to the surgery center at approximately 10:00 a.m., requesting the patient have the following tests prior to surgery: “EKG [electrocardiogram]; CBC [complete blood count], without Differential (includes Platelets); UA[urine analysis]/Culture if indicated.”

At 3:44 p.m., the patient was admitted to the surgery center for his surgical procedures. The Admission’s Nurse completed the Admission Profile with the patient and the wife, noting, among other things: “Previous hospitalizations/surgeries-microdiscectomy 2010, lumbar laminectomy 2009, with DVT after laminectomy; Comprehensive Pain Assessment­ pain scale 10, rectum, onset at 16 years old, burning; Cardiovascular-high blood pressure, weird heartbeat about 8 months ago at cardiologist; Hema/Hepatic/GI-hemorrhoids, fissure; Psychiatric-Anxiety; Social Habits-smoker 1 PPD [pack per day], alcohol 2-4 times per month.”

The general surgeon completed a Short Form history and physical for the patient, noting: “Chief Complaint-Anal pain; History of Present Illness-severe pain secondary to anal fissure. Past Medical/Surgical History: HTN [hypertension]; Current Medications and Allergies: See-home medication list; Physical Exam-Head/Neck-normal,-Airway normal,-Neuro normal, Chest/Lungs normal, Heart normal, GI normal, GU normal, Extremities normal; Significant findings-anal fissure with right posterior skin tag; Diagnosis-Anal fissure; Plan-fissurectomy, sphincterotomy, and hemorrhoidectomy; Pre-Sedation Assessment For Procedure Without an Anesthesiologist-ASA2 II – mild systemic disease.”

At 4:12 p.m., a patient provided a urine sample and blood was taken for labs. At 4:53 p.m., labs revealed normal sodium, potassium, hemoglobin, and hematocrit. At 5:11 p.m., a pre-anesthetic evaluation was completed on the patient by an anesthesiologist. At 5:29 p.m., the patient was placed under general anesthesia. At 5:46 p.m., the general surgeon performed a hemorrhoidectomy, fissurectomy, and a right lateral sphincterotomy on the patient. The surgery was completed at 6:42 p.m., and the patient was in the recovery room at 7:00 p.m. The general surgeon prescribed the patient “Norco 10/325 mg., one tablet every four hours, as needed for pain; Valium 2 mg., one every six hours, as needed for pain; and Toredal (sic) 10 mg., one every six hours.” At 8:15 p.m., The patient was discharged.

The general surgeon drafted an Operative Report, noting, among other things:

“Preoperative Diagnosis-anal fissure; Postoperative Diagnosis-anal fissure and hemorrhoids; Procedures Performed-hemorrhoidectomy, fissurectomy, right lateral internal sphincterotomy; Anesthesia-general; Findings-anal stenosis with deep posterior anal fissure with large 3-quadrent (sic) hemorrhoids in the usual distribution, in the right anterior quadrant hemorrhoidal group there with chronic strangulation and gangrenous changes.”

On 4/24/2014, Post-Surgical Day 1 (PSDl), the patient’s wife called the general surgeon’s office four times: at 9:46 a.m., 10:32 a.m., 3:10 p.m., and 4:38 p.m. At 9:46 a.m., the patient’s wife reported that the patient had blood in his urine; the patient’s wife was told that the patient had a urinary catheter during surgery and blood in the urine was normal on PSDI. At 10:32 a.m., the patient’s wife reported the patient was vomiting and had diarrhea; the patient’s wife was told this was normal for PSDl. At 3:10 p.m., the patient’s wife reported the patient was still vomiting; a prescription for Reglan (anti-nausea) was called in. The patient’s wife collected the prescription, but the patient could not keep the Reglan down.

At 4:38 p.m., the patient’s wife reported the patient was still vomiting, with diarrhea, and feels hot, although his temperature is normal; the patient’s wife was told that the symptoms are normal for PSDl, and get fluids into the patient. The general surgeon did not return the calls from the patient’s wife on 4/24/2014.

On 4/25/2014, Post-Surgical Day 2 {PSD2); at 5:58 p.m., the patient’s wife called the surgery center and reported the patient was still vomiting, with diarrhea, and feels hot; the patient’s wife was told the symptoms were normal for PSD2, but to call the general surgeon’s office. The patient’s wife called the general surgeon’s office, spoke to the answering service, and requested a callback.

At 6:40 p.m., the general surgeon telephoned the patient’s wife. The patient’s wife reported pus at the surgical site and that the stitches looked ripped open and yellow; the general surgeon said they were breakaway stitches and the appearance was normal for PSD2. They did not discuss the patient’ s symptoms from PSD 1.

On 4/26/2014, the patient began speaking nonsensically. He complained about pain in his legs. The patient’s wife called the general surgeon’s office at 12:36 p.m. and 12:40 p.m., but the office was closed for lunch and the patient’s wife did not leave a message with the exchange.

The patient’s wife then telephoned the surgery center at 12:46 p.m. and 12:47 p.m. The patient’s wife reported the patient was speaking nonsensically, with purple, blotchy legs, purple lips, and slurred speech; the patient’s wife was told to bring the patient into the hospital. At 12:58 p.in., 911 was called. Paramedics appeared and transported the patient to the surgery center.

The patient arrived at the surgery center at 1:35 p.m. In the ambulance, the patient was intubated and described by EMS as “acutely cyanotic and mottled.” Upon arrival, the patient was treated by an ED physician in the ED for two hours.

The ED physician drafted an ED Report, indicating, among other things: “This is a 36-year-old white male who comes to the emergency room by ambulance in extremis [at the point of death]. He was intubated in the field by the paramedics.”

“On arrival in the department he was purple mottled, unresponsive with a heart rate in the 60s which later proceeded to become bradycardic into the 20s.” ” … [A] temperature of 41 Centigrade [105.8 Fahrenheit] was noted.”

“Examination of the rectum revealed maceration and postoperative changes. It does appear consistent with an infection in the area.”

“Labs later returned showing renal failure with a creatinine of 9. Potassium was elevated.”

“Diagnosis-septic shock, renal failure, perineal infection, status post hemorrhoidectomy. His prognosis seems exceedingly poor.”

“Total critical care time 120 minutes.”

At 2:50 p.m., the ED physician contacted the general surgeon regarding the patient, reporting sepsis, renal failure, hyperlipidemia, recent hemorrhoidectomy with local infection. The general surgeon telephoned the surgery center to reserve an OR for the patient, scheduling the first available OR at 5 p.m.

At approximately 3:30 p.m., the patient was admitted to the surgery center and his care was transferred to an internist. After 5:00 p.m., the patient was taken to interventional radiology (IR) for placement of an IVC [inferior vena cava] filter (5:35 p.m.) and a temporary dialysis catheter (5:43 p.m.).

At 5:50 p.m., the patient was moved from IR into the OR, where the general surgeon waited. On arrival to the OR, the transport staff reported a change in heart rhythm. A Code Blue was called at 6:05 p.m. Resuscitative measures commenced but were unsuccessful, and time of death was called at 6:41 p.m.

The internist charted a Discharge Summary, noting: “Discharge Diagnosis-(1) patient died, (2) severe septic shock, (3) most likely perirectal phlegmon [inflammatory process with pus] versus fasciitis [inflammation of connective tissue]. History of Hospital Stay-This was a 36-year-old gentleman admitted at [the hospital] with septic shock. He was hypotensive, unresponsive, intubated in the field. While in the emergency room, the patient had episodes of bradycardia [abnormally slow heart action]. He was found to have multi-organ system failure with acute kidney insufficiency. He was taken to the OR for an emergent exploratory laparotomy [a surgical incision into the abdominal cavity, for diagnosis or in preparation for surgery]. Unfortunately, he coded on the OR table.”

The general surgeon wrote a Death Note in the chart, indicating: “Patient came in with septic shock. Code blue called in route to OR. CPR commenced in the OR per ACLS [advanced cardiac life support] protocol. Planned perineal debridement and colostomy never took place. Code was called after 22 min of resuscitative effort then resumed after seemingly having spontaneous cardiac electrical activity and pulse, but this was transient, and soon patient became pulseless without meaningful cardiac activity. Patient after hemorrhoidectomy and has perineal gangrene.”

An autopsy was performed on April 28, 2012, at the Fresno County Coroner’s Office. A blood culture was taken, revealing gram-negative rods isolated [bacterial infection]. The cause of death is listed as probable cardiac arrhythmia due to idiopathic hypertrophic cardiomyopathy.

The general surgeon was placed on probation for three years with stipulations of completing an education course and undergoing monitoring by another physician.

State: California


Date: May 2017


Specialty: General Surgery, Internal Medicine


Symptom: GI Symptoms (GERD, Abdominal Distention, Dysphagia), Fever, Nausea Or Vomiting, Pain, Urinary Problems


Diagnosis: Sepsis


Medical Error: Delay in proper treatment, Failure of communication with patient or patient relations, Improper treatment


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



New York – Internal Medicine – Chronic Fatigue, Disturbed Sleep, Joint Pains, Nausea, Diarrhea, And An Abnormal MRI Diagnosed As Chronic Fatigue Syndrome



From 10/15/1998 to 3/7/2008, Physician A treated a 38-year-old female who presented with complaints of severe fatigue, disturbed sleep, irritability, joint pains, frequent sore throats, nausea, and diarrhea.  At her initial visit, the patient reported that 9 years earlier she had been told she had a borderline Lyme test and was treated with antibiotics.  In the past 5 years, she had frequent bouts of fatigue and was diagnosed with Chronic Fatigue Syndrome.

In December 1998, the patient was seen by a neurologist who, based on an abnormal MRI, recommended a lumbar puncture but one was not done.  In June 1999, the patient had an abnormal brain SPECT.  In January 2002, the patient had her first and only physical examination at Physician A’s practice.  In January 2008, ten years after the initial MRI, the patient had a second MRI, which was again abnormal.  A neurologist performed a lumbar puncture.

The results of the lumbar puncture were negative for Lyme disease but revealed positive oligoclonal band proteins which are consistent with the diagnosis of multiple sclerosis.

The Board judged Physician A’s conduct to have fallen below the standard of care given failure to take an adequate history of present illness, failure to obtain prior medical records, failure to perform a physical examination, failure to construct a differential diagnosis, failure of prescribing medications without appropriate medical conditions, failure to perform a lumbar puncture, and failure to timely diagnose the patient’s multiple sclerosis.

The Board charged Physician A with professional incompetence and gross negligence.

State: New York


Date: April 2017


Specialty: Internal Medicine, Family Medicine, Neurology


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


Diagnosis: Neurological Disease, Autoimmune Disease


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Family Medicine – Patient With Hypotension And Tachycardia Treated With 2 Liters Of Intravenous Normal Saline



On 11/12/2013, a patient presented with complaints of nausea, vomiting, and abdominal pain.  The patient also had a history of deep vein thrombosis (DVT) and renal cell carcinoma.

The patient’s pertinent physical findings included a hypotensive blood pressure of 84/56 and a pulse of 158 beats per minute.  The patient received two liters of intravenous normal saline without improvement in his blood pressure.

On 11/13/2013, at 2:00 a.m., a family practitioner admitted the patient to the hospital and implemented a plan of care to include a routine lab work, normal saline, chest x-ray, and medications.

The family practitioner failed to address the patient’s history of DVT and anticoagulation therapy.

At 3:50 a.m., the patient suffered a fall, became unresponsive, and could not be resuscitated.

The prevailing standard of care in an urgent care setting is to identify the patients who can be treated with basic intervention and be safely discharged to the ambulatory setting, or alternatively to identify the patients who are at risk of losing life or limb and must be transferred to a higher level of care where resources are available to address, diagnose, and treat the life-threatening condition in a timely manner.

The Medical Board of Florida judged the family practitioner’s conduct to be below the minimal standard of competence given that he failed to recognize and address the patient’s grossly abnormal vital signs, which included a heart rate of 158 beats per minute and a systolic blood pressure under 100 mmHg, which did not stabilize after an intravenous fluid bolus.  The family practitioner also failed to treat the patient with more aggressive intravenous fluid resuscitation.  He failed to order STAT lab work, instead of routine lab work.  He failed to acknowledge, document, or treat the patient’s anticoagulated blood by reversing the anticoagulation with intravenous vitamin K and transfusing fresh frozen plasma.

The Medical Board of Florida issued a letter of concern against the family practitioner’s license.  The Medical Board of Florida ordered that the family practitioner pay a fine of $7,500.00 against his license and pay reimbursement costs for the case at a minimum of $2,023.11 and not to exceed $4,023.11.  The Medical Board of Florida also ordered that the family practitioner complete five hours of continuing medical education in emergency medicine and five hours of continuing medical education in “risk management.”

State: Florida


Date: April 2017


Specialty: Family Medicine, Emergency Medicine, Internal Medicine


Symptom: Abdominal Pain, Nausea Or Vomiting


Diagnosis: Cardiovascular Disease


Medical Error: Underestimation of likelihood or severity, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Improper medication management


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Kansas – Physician Assistant – High Dosing Regimen Of Amitriptyline For A Pediatric Patient With Headache, Vomiting, And Incontinence



On 11/19/2015, a patient presented to a physician assistant at a family care clinic with chief complaints of headache, vomiting, and incontinence since 11/17/2015.  The patient’s father reported, in addition to the severe headache, the patient was experiencing involuntary arm jerking.  Furthermore, the night prior, the patient experienced hearing voices.

The patient had a history of respiratory problems, was noted to have “poor” functional status, and was noted to be in preschool.

The physician assistant did not complete a neurological examination; however, he diagnosed the patient with pediatric migraine and ordered thirty 10 mg tablets of amitriptyline with instructions for the patient to take one tablet three times daily and the patient was to have one refill.  The physician assistant did not perform a thorough workup to include additional studies or tests prior to prescribing amitriptyline.

On 2/3/2016, the Board received a response from the physician assistant wherein he indicated, “I recall little about the episode, except possibly after reviewing his chart and the nurses [sic] report, in investigating his headache and cyclic vomiting and physical exam in UpToDate that the treatment I initiated would have been per the UpToDate recommendations.”

UpToDate is an online website claiming to be an evidence-based, physician-authored clinical decision support resource.

The physician assistant inappropriately prescribed amitriptyline due to the excessive dose and age of the patient.

The Board judged the physician assistant’s conduct to be below the minimum standard of competence given his inappropriate prescribing of amitriptyline.

For this allegation and others, the Board ordered the physician assistant to contact The Center for Personalized Education for Physicians, (“CPEP”) for a competence assessment, follow all recommendations of the CPEP assessment, and complete a medical record keeping seminar.

State: Kansas


Date: April 2017


Specialty: Physician Assistant, Family Medicine, Pediatrics


Symptom: Headache, Nausea Or Vomiting, Psychiatric Symptoms, Urinary Problems


Diagnosis: Neurological Disease


Medical Error: Improper medication management, Accidental Medication Error, Failure to examine or evaluate patient properly


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Cardiology – CT Coronary Angiogram On Hemodynamically Compromised Patient For Chest Pain, Abnormal Electrocardiogram, Right Atrial Enlargement, And Elevated Cardiac Enzymes



On 4/16/2012, a 23-year-old female presented to the emergency department with chest pain, acute nausea, vomiting, and diarrhea.  The patient had a history of pulmonary hypertension. Laboratory measurements were taken that revealed a hemoglobin of 17.2, hematocrit of 49.9, an acidotic pH of 7.12, an elevated WBC count of 15,900, potassium of 6.6, BUN of 31, and creatinine level of 1.4.  These measurements were consistent with mild renal insufficiency. An electrocardiogram test revealed sinus tachycardia, which was consistent with the findings of an electrocardiogram performed on the patient approximately 1 year earlier.

On 4/17/2012, the patient was admitted to the hospital.  The patient was initially treated with sodium bicarbonate to treat her lactic acidosis and IV fluids for dehydration.  The patient also received a dialysis catheter in her right femoral artery due to the increase in the BUN/creatinine measurements.  However, this catheter was never used.

On 4/17/2012, a cardiologist performed a telephonic cardiology consult with the hospitalist and ordered a CT coronary angiogram due to the patient’s chest pain, abnormal electrocardiogram, right atrial enlargement, and elevated cardiac enzymes (troponin).  The cardiologist also ordered 100 ml of ionic contrast to facilitate the CT angiogram despite the patient’s continued elevated BUN and creatinine levels. The cardiologist also ordered 50 mg of metoprolol orally and 5 mg intravenously to improve visualization on the CT angiogram despite the patient’s clinical condition.  The cardiologist did not perform a physical examination of the patient, measure the patient’s pulmonary pressure, or review the patient’s diagnostic or laboratory tests prior to ordering ionic contrast, CT angiogram, or administering metoprolol.

On 4/17/2012, the patient deteriorated and became hypotensive approximately 90 minutes after the CT angiogram and administration of metoprolol.  At approximately 8:00 p.m., the patient expired due to cardiac arrest.

The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because he failed to physically examine the patient prior to ordering a potentially dangerous procedure and drugs, review the patient’s previous diagnostic testing and laboratory testing prior to ordering a potentially dangerous procedure and drugs, and order a pulmonary artery catheter to measure pulmonary pressure in a hemodynamically compromised patient.

The Medical Board of California placed the cardiologist on probation for 3 years and ordered the cardiologist to complete a medical record keeping course and an education course (at least 40 hours per year for each year of probation).  The cardiologist was also assigned a practice monitor.

State: California


Date: March 2017


Specialty: Cardiology


Symptom: Chest Pain, Diarrhea, Nausea Or Vomiting


Diagnosis: Cardiovascular Disease, Renal Disease, Sepsis


Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Improper medication management


Significant Outcome: Death


Case Rating: 5


Link to Original Case File: Download PDF



California – Gastroenterology – Second Colonoscopy Performed Within Days Of First Due To Concerns Of Suboptimal Bowel Preparation



On 1/6/2010, an 84-year-old patient was admitted to the hospital with complaints of dizziness, anemia, and possible GI bleeding.  On 1/8/2010, a gastroenterologist provided a GI consultation for the patient. The gastroenterologist’s handwritten note on that date was cursory and lacking in detail without documenting a comprehensive history, comprehensive physical examination, and/or the gastroenterologist’s medical decision-making.  The gastroenterologist submitted billing for the consultation using CPT billing code 99223, which was not supported by the gastroenterologist’s documentation of the visit.

On 1/9/2010, the patient underwent a gastroscopy.  Small gastric natural ulcers and a bulbar duodenal ulcer, which was 2.5 cm in size, were identified and cauterized.  Sometime later in January 2010, the patient was readmitted to the hospital with complaints of nausea, vomiting, diarrhea, weakness, and interval decline in hemoglobin.  The patient underwent laboratory tests, which showed anemia with borderline iron deficiency.

On 1/27/2010, the patient underwent both a gastroscopy and a colonoscopy.  Small oozing angiodysplasias were found in the duodenum and were cauterized.  Small adenomatous polyps were excised from the distal colon. On 2/1/2010, the patient underwent a second colonoscopy due to concerns that pathology may have been missed due to suboptimal bowel preparation during the first examination.

The Medical Board of California judged that the gastroenterologist’s conduct departed from the standard of care because he performed a medically unnecessary second colonoscopy on 2/1/2010 within days of an initial colonoscopy, his documentation was cursory and some of the physician’s handwritten notes were illegible, and he submitted billing using the CPT billing code 99223, which was not supported by the physician’s documentation of his care and treatment of the patient.

For this case and others, the Medical Board of California issued a public reprimand and ordered the gastroenterologist to complete an education course (at least 40 hours) and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California


Date: February 2017


Specialty: Gastroenterology


Symptom: Dizziness, Diarrhea, GI Symptoms (GERD, Abdominal Distention, Dysphagia), Nausea Or Vomiting, Weakness/Fatigue


Diagnosis: Gastrointestinal Disease


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


Significant Outcome: Hospital Bounce Back


Case Rating: 2


Link to Original Case File: Download PDF



California – Gastroenterology – Repeated Colonoscopies And Gastroscopies For Worsening Esophagitis And Billing For Complex Evaluation



On 4/21/2010, a 58-year-old was admitted to the hospital with chest and abdominal pain, nausea, vomiting, and leukocytosis.  The patient was seen by a gastroenterologist for GI consultation.

On 4/29/2010, the patient underwent a gastroscopy, which revealed erosive esophagitis, Los Angeles grade B, and “small ulcers with overlying semi fresh blood” were cauterized.

On 5/21/2010, the patient was re-hospitalized with complaints of persistent abdominal pain.  On 5/28/2010, a second gastroscopy was performed. The ulcers that were previously found had resolved.  The gastroenterologist biopsied the gastric antrum. The reasons for doing so were not documented in the patient’s medical chart.  The patient continued to experience pain, but the medical records did not characterize the pain complaints.

On 6/2/2010, the patient underwent a colonoscopy.  It was unclear from the medical documentation whether the colonoscopy was performed on an urgent basis.  During the study, the gastroenterologist removed small, benign polyps. The gastroenterologist recommended a repeat colonoscopy due to suboptimal bowel preparation.

On 6/15/2010, the patient was hospitalized with complaints of nausea and vomiting.  On 6/19/2010, a third gastroscopy was performed and revealed mild esophagitis. Sometime in August 2010, the patient was hospitalized with complaints of abdominal pain, nausea, and vomiting.  On 8/11/2010, a fourth gastroscopy was performed, which the gastroenterologist interpreted as showing “extensive ulcerative esophagitis with multi foci of blood.”

On 5/24/2011, the patient underwent a fifth gastroscopy, which the gastroenterologist interpreted as showing esophagitis and numerous erosions or superficial ulceration in the lower stomach.  Also on this date, the patient underwent a second colonoscopy, and the gastroenterologist recommended a “follow-up colonoscopy after a more thorough prep.”

The Medical Board of California judged that the gastroenterologist’s conduct departed from the standard of care because he performed repeated gastroscopic examinations of the patient without medical indication or necessity, failed to maintain adequate or accurate records regarding his care and treatment of the patient, and submitted billing for each hospital visit with the patient using CPT billing code 99233, or a complex evaluation, which was not supported by the gastroenterologist’s documentation of the visits.

For this case and others, the Medical Board of California issued a public reprimand and ordered the gastroenterologist to complete an education course (at least 40 hours) and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California


Date: February 2017


Specialty: Gastroenterology


Symptom: Chest Pain, Nausea Or Vomiting, Abdominal Pain


Diagnosis: Gastrointestinal Disease


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


Significant Outcome: Hospital Bounce Back


Case Rating: 2


Link to Original Case File: Download PDF



California – Gastroenterology – Hemorrhoids Cauterized During Multiple Colonoscopies



A 58-year-old had a history of diabetes and generalized atherosclerotic vascular disease.  On 12/18/2009, the patient underwent an outpatient colonoscopy to assess complaints of diarrhea and abdominal pain.  The study was interpreted to show mild colitis, but biopsies were normal.

On 2/10/2010, the patient complained of abdominal discomfort and reflux-type symptoms.  The patient underwent a gastroscopy with finding of mild esophagitis and gastritis. Following placement of a stent and initiation of anticoagulation therapy, the patient presented with GI bleeding with bloody stools and hemoglobin decline necessitating multiple transfusions.

On 3/15/2010, the patient underwent a second gastroscopy, which the gastroenterologist interpreted to show multiple bleeding gastric ulcers.  The gastroenterologist cauterized the bleeding gastric ulcers with a BICAP probe. The patient continued to have bloody stools.

On 3/18/2010, the patient underwent a second colonoscopy and a third gastroscopy.  The gastroenterologist again interpreted the gastroscopy to show hemorrhagic erosions, which he again cauterized.  The colonoscopy was technically inadequate due to retained blood and debris.

On 3/20/2010, the patient underwent a third colonoscopy.  The gastroenterologist interpreted a finding of sigmoid diverticulosis.  On 6/4/2010, the patient was re-hospitalized with complaints of nausea, vomiting, weakness, and dark stools.  The patient was receiving antiplatelet therapy following a vascular intervention. On 6/4/2010 or 6/5/2010, the patient was seen by the gastroenterologist for GI consultation.  The gastroenterologist’s dictated consultation note was cursory, making no mention of the patient’s complaints or contributory medications. The gastroenterologist billed for the consultation using CPT billing code 99254, indicating a Level 4 consultation, which was not documented in the gastroenterologist’s consultation note.

On 6/5/2010, the patient underwent a fourth gastroscopy.  The gastroenterologist, again, cauterized “hemorrhagic erosion with evidence of slow bleed.”  On 6/7/2010, the patient underwent a fourth colonoscopy due to concerns of a lower GI tract contribution to bleeding.  The patient was found out have internal hemorrhoids, which the gastroenterologist cauterized.

The Medical Board of California judged that the gastroenterologist’s conduct departed from the standard of care because he performed repeated upper and lower endoscopic examinations of the patient in the absence of important pathology to justify the repeat studies, failed to maintain adequate and accurate medical records of his care and treatment to the patient, and submitted billing for his care and treatment of the patient using the CPT billing code 99254, which was not supported by the physician’s documentation.

For this case and others, the Medical Board of California issued a public reprimand and ordered the gastroenterologist to complete an education course (at least 40 hours) and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California


Date: February 2017


Specialty: Gastroenterology


Symptom: Diarrhea, Blood in Stool, GI Symptoms (GERD, Abdominal Distention, Dysphagia), Nausea Or Vomiting, Abdominal Pain, Weakness/Fatigue


Diagnosis: Gastrointestinal Disease


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


Significant Outcome: Hospital Bounce Back


Case Rating: 2


Link to Original Case File: Download PDF



California – Gastroenterology – Multiple Endoscopic Studies For Ulcerative Esophagitis



A patient had been seen by a gastroenterologist, as an outpatient, since sometime in 2005 for chronic gastroesophageal reflux disease (GERD).  The patient had received long-term treatment with acid-reducing medications and prokinetic agents. Between 2005 and 2009, the patient underwent 23 separate endoscopic studies.  The gastroenterologist’s hand-written documentation of his care and treatment of the patient was scant, illegible, and failed to state the gastroenterologist’s thoughts regarding evaluating and/or modifying the patient’s clinical course.

Sometime in June 2010 and again in July 2010, the patient was admitted to the hospital with upper GI tract bleeding.  On 7/13/210, the gastroenterologist dictated an admission summary, which failed to provide any meaningful historical details regarding the patient.  The gastroenterologist used PT billing code 99223 indicating a “complex” level of assessment for the consultation.

From 6/16/2010 through 10/9/2010, the gastroenterologist performed a total of 7 endoscopic studies to evaluate the patient.  The studies demonstrated that the patient had severe ulcerative esophagitis, secondary to reflux and/or vomiting. The gastroenterologist documented that he cauterized areas of hemorrhagic mucosa in the esophagus.  However, the gastroenterologist’s dictated procedure reports failed to document any additional anatomy or physiology related to these studies and treatment.

The Medical Board of California judged that the gastroenterologist’s conduct departed from the standard of care because he failed to properly manage the patient’s reflux disease, performed an excessive number of endoscopic procedures that provided no relief to the patient’s symptoms or improvement in clinical outcome, failed to maintain adequate or accurate records of his care and treatment of the patient, and submitted billing using the CPT billing code 99223, which as not supported by the physician’s documentation of his care and treatment of the patient.

For this case and others, the Medical Board of California issued a public reprimand and ordered the gastroenterologist to complete an education course (at least 40 hours) and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California


Date: February 2017


Specialty: Gastroenterology


Symptom: GI Symptoms (GERD, Abdominal Distention, Dysphagia), Bleeding, Nausea Or Vomiting


Diagnosis: Gastrointestinal Disease


Medical Error: Unnecessary or excessive diagnostic tests, Improper treatment, Lack of proper documentation


Significant Outcome: Hospital Bounce Back


Case Rating: 2


Link to Original Case File: Download PDF



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