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Beginning in June 2014, a physician began treating Patients A and B for thyroid dysfunction and Patient C for high blood pressure. The physician communicated with Patient A and B through phone consultation and met Patient C in social situations and during at least two office visits. The physician reviewed previous lab work on thyroid functions for Patients A and B. The physician based Patient C’s treatment upon his physical observation of her conditions, two Zytoscans (device that measures electrical currents in the skin), and taking her blood pressure. Patient A and B’s lab work indicated both patients having lower than normal thyroid function. The physician started both Patients A and B on a thyroid hormone supplement. He prescribed medication commonly used for treating high blood pressure for Patient C based upon his observations, oral reports of Patient C, and the Zytoscans. The physician failed to do lab work, took minimal chart notes, and did not schedule follow-up examinations for Patients A, B, or C.

For several months, the physician continued prescribing for Patients A, B, and C without ever seeing the patients in person for further work up. The physician’s interactions with Patients A and B were solely over the phone, while the physician notes state that he had two office visits with Patient C. The physician did not order thyroid stimulating hormone (TSH) testing to further verify if continuing the thyroid hormone supplement would be appropriate in managing Patient A and B’s conditions.

In June 2015, Patient A presented to another provider with concerns of heart palpitations. Patient A told the provider he noticed the palpitations reduced when he reduced his thyroid hormone supplement dosage. During this consultation, Patient A disclosed his treatment with the physician which alerted the provider to have Patient A’s TSH levels checked. Patient A’s lower than normal TSH result prompted the provider to immediately begin weaning Patient A off of his thyroid hormone supplement.

Patient B also presented to the same provider in June 2015. At her visit, Patient B presented with a rash on her chest which she had for over a month. The new provider assessed the rash being unrelated to her treatment with the physician; however, due to her receiving similar treatment as Patient A, the provider had Patient B’s TSH level tested. Patient B’s results indicated her TSH level was below the normal range.

On 8/26/2015, the physician saw Patient C for what he thought was a urinary tract infection. The physician first prescribed Keflex but changed it to ciprofloxacin based upon the results of a Zytoscan. Caution is required when giving ciprofloxacin to patients with hypokalemia.

On or about 9/9/2015, Patient C presented to the hospital emergency department where she was diagnosed with significant hypokalemia (lowered levels of potassium in the blood) and hyponatremia (lowered levels of sodium in the blood) which caused Patient C to suffer fatigue and heart palpitations. Patient C went immediately from the emergency department to a new care provider. After an oral interview with Patient C, the new care provider learned that Patient C was taking a number of medications prescribed by the physician. The new care provider attempted to contact the physician a number of times to obtain the physician’s chart notes, lab studies, and other medical records for Patient C but was unsuccessful. Patient C told her new care provider that the physician had been giving her medications for a number of years. She stated, “I tell him what I need.” In the physician’s response to the Commission, he stated that “if [Patient C] called me to have a prescription filled, I would do that for her.”

The Commission stipulated the physician reimburse costs to the Commission and write and submit a paper of at least 2000 words, with references and annotated bibliography, regarding Washington State rules for physicians forming and maintaining patient/physician relationships, the differential diagnosis of hyperthyroidism and hypothyroidism, the proper monitoring of electrolyte levels for patients with high blood pressure, and the importance of complying with Commission sanctions.

State: Washington

Date: November 2017

Specialty: Internal Medicine, Family Medicine

Symptom: Palpitations, Rash

Diagnosis: Endocrine Disease

Medical Error: Failure to follow up, Failure to properly monitor patient, Improper medication management

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF

On 2/6/2013 a patient’s father contacted EMS (emergency medical services) because his son had respiratory distress, fever, and an elevated heart rate.

EMS documented a heart rate of 278 and performed a pre-hospital EKG because ventricular tachycardia (VTach) was a concern.  EMS contacted the hospital to report vital signs and their impression of VTach.

The patient presented to the emergency department at 11:29 p.m.  The patient was triaged at 11:42 p.m. and a pulse of 245, blood pressure of 53/39, and a temperature of 101.02 were recorded.  An EKG was performed at 11:43 p.m.  The results were shown to the ED physician at 11:47 p.m.

The ED physician’s notes state that at 12:13 a.m. the patient was examined.  It was documented that the ED physician suspected the patient was in VTach, but no therapy was administered.

The ED physician then contacted the on-call cardiologist, who advised the ED physician to treat the patient for probable sepsis with fluids and Tylenol.  The ED physician then ordered IV antibiotics and spoke to a critical care physician about transfer of the patient.

At 12:29 a.m. the patient had a ventricular fibrillation cardiac arrest.  He was treated with various medications but no shock was given.  At 12:45 a.m. the patient was pronounced dead.

The Board concluded that the ED physician be reprimanded, complete 15 hours of continuing education on Advanced Cardiac Life Support, and pay a fine of $1000.

State: Vermont

Date: September 2017

Specialty: Emergency Medicine, Cardiology

Symptom: Shortness of Breath, Fever, Palpitations

Diagnosis: Cardiac Arrhythmia

Medical Error: Improper treatment, Delay in proper treatment

Significant Outcome: Death

Case Rating: 3

Link to Original Case File: Download PDF

On 2/20/2012, a 31-year-old female presented to the medical emergency department with abdominal pain and shortness of breath.

On 2/20/2012 at 2:06 p.m., the patient had a blood pressure of 147/81 and a heart rate of 165 beats per minute.  At 2:52 p.m., the patient had a heart rate of 153 beats per minute.  At 3:24 p.m., the patient had a blood pressure of 94/40 and a heart rate of 132 beats per minute.  At 4:08 p.m., the patient had a heart rate of 157 beats per minute.  At 6:04 p.m., the patient had a blood pressure of 98/50 and a heart rate of 145 beats per minute.

From 2:06 p.m. until 6:04 p.m., the patient was sinus tachycardic and hypotensive.

At 6:52 p.m., an internal medicine practitioner on the unit was advised of the patient’s consistent elevated heart rate.  From 6:52 p.m., the internist was the physician treating the patient.

At 7:00 p.m., the internist ordered the administration of 10 mg of diltiazem to the patient one time, over two minutes.

At 7:10 p.m., the patient had a palpated systolic pressure of 80 and a heart rate of 125 beats per minute.  The patient’s medical records indicated that due to the patient’s low blood pressure, 5 mg of diltiazem was administered over five minutes.

Diltiazem is not indicated for the treatment of sinus tachycardia. Diltiazem is contraindicated in the setting of hypotension. Diltiazem is contraindicated in the setting of hypotension and sinus tachycardia.

The patient’s medical records include a correction that indicates that additional vital signs were obtained at 6:43 on 2/20/2012.  According to that record, the patient had a blood pressure of 186/76 and a heart rate of 82 beats per minute.

Diltiazem is not indicated for a patient with a blood pressure of 186/76 and a heart rate of 82 beats per minute.

Ultimately, the patient died after a hospitalization lasting 4 weeks.  A lawsuit was filed alleging the patient was not transferred to an ICU in a timely fashion.  There were no ICU beds available at the hospital where she had been treated.  The suit alleged the hospital should have transferred the patient to another hospital with an available ICU bed.

In the lawsuit, it was noted that the patient had developed diabetic ketoacidosis, severe metabolic acidosis, and pancreatitis.  After she was administered the doses of diltiazem mentioned above, she went into cardiac arrest before transfer to an ICU.  It was noted that the patient was held in the emergency department from the time of her arrival at 1:52 p.m. until her transfer at 12:10 a.m. the following day (for a total of over 10 hours).  On 3/18/2012, she died.

The Board judged the internists conduct to be below the minimal standard of competence given that he ordered the administration of diltiazem to a patient when diltiazem was not indicated and/or was contraindicated.

The Board issued a letter of concern against the internist’s license.  The Board ordered that the internist pay an administrative fine of $5,000 against his license and pay reimbursement costs for the case for $10,000.  The Board also ordered that the internist complete ten hours of continuing medical education in “internal medicine” and five hours of continuing medical education in “risk management.”

State: Florida

Date: June 2017

Specialty: Internal Medicine, Emergency Medicine, Endocrinology

Symptom: Palpitations, Abdominal Pain

Diagnosis: Cardiovascular Disease

Medical Error: Improper medication management

Significant Outcome: Death

Case Rating: 4

Link to Original Case File: Download PDF

On 1/25/2016, a patient reported to the emergency department for treatment of the ingestion of a large dose of Zoloft in an apparent suicide attempt.  The patient reported that she took the medication approximately four hours prior to her arrival to the emergency department.  The patient indicated she had a twenty-seven-year history of depression.

The emergency department notes indicated that the patient suffered nausea, vomiting, and tachycardia.  After successful treatment of the patient’s drug ingestion, she was still deemed to be at risk for suicide, and inpatient treatment was recommended.  The patient was stabilized after a course of inpatient treatment and subsequently discharged.

On 3/21/2016, the physician that had prescribed the Zoloft told the Commission that the patient had received a consistent dose of Zoloft from primary care providers for approximately eight to ten years for treatment of depression.  The physician indicated that he provided the patient with prescriptions for Zoloft on two or three occasions since 2010 to avoid interruptions in her ongoing regimen, due to difficulties establishing timely medical appointments and changes with insurance provider procedures.  When writing the patient’s prescription for Zoloft, the physician used his typical prescription language allowing renewals to be refilled for up to one year.  The physician did not document the prescriptions or physical assessment of the patient in the medical record.

The physician failed to meet the standard of care in prescribing Zoloft for the patient when he provided her, a patient with a twenty-seven-year history of depression, with a year supply of medication on several occasions without proper evaluation or follow-up of her condition.

The Commission stipulated the physician reimburse costs to the Commission, complete a live/in-person course on prescribing medications, and write and submit a paper of at least one thousand words, plus bibliography, addressing the risks of prescribing medications without appropriate clinical oversight and recordkeeping.

State: Washington

Date: August 2016

Specialty: Psychiatry

Symptom: Nausea Or Vomiting, Palpitations

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

Medical Error: Improper medication management

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF

The Board received notice of a malpractice settlement.

On 12/03/2012, a 63-year-old female presented to urgent care.  The patient’s boyfriend completed her health history document and provided the urgent care physician (UC physician) with information on the patient’s current medications and her history of a motor vehicle accident a year prior to the appointment.  She was noted to have a history of frequent and severe headaches.

The patient’s current symptoms included shortness of breath, “palpitations or pounding heart…chest pain or pressure,” “nausea and vomiting,” and “numbness of the arms or legs.”  The patient reportedly had neck or back pain with “numbness of the arms or legs.”

The medical assistant (MA) completed the Urgent Care “Abdomen/Groin GI/GU” encounter form.  On the form, the MA noted the patient’s blood pressure to be 106/68 with respirations of 18, “O2 99%,” and a temperature of 95.5.  The UC physician wrote on the same encounter form that the patient had been experiencing symptoms, which included four hours of vomiting and myalgia.  The UC physician noted that the patient felt like she had impending diarrhea.

The encounter documentation stated that she had a history of a cholecystectomy and an appendectomy.  The UC physician checked off current patient symptoms of nausea, vomiting, and chills.  He checked boxes indicating a “no” to constipation, fever, black stools, diarrhea, flank pain, heartburn, jaundice, dysuria, hematemesis, hematuria, dyspepsia, fatty food intolerance, and post-prandial pain.

In his objective notations, the UC physician noted only a single finding of abdominal tenderness by checking “yes.”  He checked “no” to 18 other exam findings which included the cardiac, pulmonary, skin, neurologic, gastrointestinal, and genitourinary systems along with mental status.

The UC physician’s diagnosis was listed as gastroenteritis and “viral syndrome” was checked as “no.”  The UC physician concluded the written record by indicating “medications” and giving prescriptions for prochlorperazine 25 mg, OTC Imodium, and Pepcid AC.  He also noted that he had counseled the patient on her diet.

At 10:00 a.m. on 12/04/2015, there was a final entry in the patient’s record, a handwritten note, that the Scottsdale Police had contacted the UC physician informing him that the patient was found unresponsive on that morning and that the paramedics could not revive her.

An autopsy on the patient revealed a 95% atherosclerotic occlusion of the major coronary arteries, ventricular hypertrophy, acute coronary artery thrombosis, pericarditis, chronic pulmonary and renal disease, and an adrenal mass.  The cause of death was acute myocardial infarction.

The Board judged the UC physician’s conduct to be below the minimum standard of competence given failure to diagnose acute myocardial infarction.

The Board ordered the UC physician to be reprimanded.

State: Arizona

Date: June 2016

Specialty: Emergency Medicine, Internal Medicine

Symptom: Chest Pain, Constipation, Nausea Or Vomiting, Numbness, Back Pain, Head/Neck Pain, Palpitations, Shortness of Breath

Diagnosis: Acute Myocardial Infarction

Medical Error: Diagnostic error

Significant Outcome: Death

Case Rating: 2

Link to Original Case File: Download PDF

On 12/10/2014, a patient, a resident of an inpatient psychiatric facility, fell on his face during a fire drill.  Per ward staff, it appeared the patient had experienced a seizure.  An on-the-scene physician ordered labs for the next morning, checked the patient’s vital signs, performed a dental consult, and provided a dose of antibiotic and some Gatorade.

On 12/11/2014, the same physician examined the patient and noted his pulse to be 90-100, after an initial measurement of 113, and his blood pressure stable.  Soon after, a second physician performed an examination on the patient and noted that he was “feeling generally unwell, had a low grade temperature and some muscle pain.”  It appeared to the physician the patient had an upper respiratory infection.  Albuterol and a complete blood count were ordered.

On the afternoon of 12/11/2014, a third physician examined the patient.  The physician’s records showed the patient presented with a probable upper respiratory virus with asthmatic bronchitis.  The patient’s heart rate was 120.  The physician documented that the patient’s tachycardia was probably due to mild dehydration and medications.  The treatment plan for the patient included a chest x-ray and evaluation of creatine phosphokinase (CPK) levels.  It was reported that the patient’s chest x-ray “seemed negative.”  The patient denied having any chest pain.  The physician opined that the increased CPK level may have been caused by medications or a possible recent seizure.  The physician’s treatment plan included an electrocardiogram (ECG), rechecking labs, and oral hydration.

On 12/12/2014, an internist entered the patient’s medical room.  She ordered fluid monitoring every shift, continuation with vital signs every four hours, and repeat lab testing in the morning.  The ECG reported “probably abnormal ECG.”  The internist was notified of this reporting and informed an assisting physician.

The internist failed to review the patient’s previous medical records, which included chest x-rays and perpetuated the diagnosis of dehydration despite adequate hydration.  The internist failed to respond to abnormal vital signs and properly diagnose and treat the patient’s medical condition.  The internist also failed to transfer the patient to a higher level of care for additional work-up.

On 12/13/2014,  the patient’s treating psychiatrist received a call from the nursing staff informing her the patient was suffering from an elevated heart rate, and had an elevated, though declining, CPK level.  The patient continued to receive treatment from various physicians who noted the patient’s decline, which included symptoms of tachycardia and weakness.

On 12/14/2014, the patient was transported to a hospital by ambulance where diagnostic tests revealed “extensive bilateral pulmonary emboli and probably thrombus in the right atrium.” The patient was transported to a second hospital.  While in interventional radiology, the patient became pulseless and was later pronounced dead.

The Commission stipulated the internist reimburse costs to the Commission and write and submit a paper of at least 1000 words on how to appropriately evaluate patients with shortness of breath and tachycardia.  The paper should also discuss the proper review of ECG findings consistent with pulmonary embolisms.

State: Washington

Date: March 2016

Specialty: Internal Medicine

Symptom: Palpitations, Shortness of Breath, Weakness/Fatigue

Diagnosis: Pulmonary Embolism

Medical Error: Diagnostic error

Significant Outcome: Death

Case Rating: 5

Link to Original Case File: Download PDF

The Board was notified of a professional liability payment.

On 04/05/2011, a patient presented to the emergency department with complaints of racing heart, chest tightness, and shortness of breath.  The patient had a history of deep vein thrombosis.  A series of tests were ordered, including a d-dimer test, to rule out the possibility of venous thrombosis or pulmonary embolism.

The patient was discharged prior to the result of the d-dimer test being available and thus prior to the ED physician reviewing it.  After the patient left the emergency department, the d-dimer results returned with a value of 12 (normal < 0.5).

Approximately 1.5 hours later, the patient became symptomatic again and was transported to another facility.  The patient underwent a CT angiography of the chest, which revealed a pulmonary embolism.  Several hours later the patient died of pulmonary emboli.

The Board judged the ED physician’s conduct to be below the minimum standard of competence given failure to wait for a test result to be completed prior to discharge the patient.  The Board noted that the admitting physician and internist at the second hospital delayed starting anticoagulation therapy, which may have decreased the chance of patient recovery.

The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards.  It was not reported to the National Practitioner Data Bank.

State: North Carolina

Date: July 2015

Specialty: Emergency Medicine

Symptom: Shortness of Breath, Chest Pain, Palpitations

Diagnosis: Pulmonary Embolism

Medical Error: Diagnostic error

Significant Outcome: Death, Hospital Bounce Back

Case Rating: 2

Link to Original Case File: Download PDF

A family practitioner saw a patient from 4/15/2002 through 4/27/2006 and never referred the patient for any ultrasounds until the family practitioner got his machine in November 2006.  The family practitioner then completed four carotid ultrasounds (August 2006, December 2007, January 2009, and January 2010), three echocardiograms (November 2006, October 2008, and November 2009), three abdominal ultrasounds (August 2007, August 2008, and September 2009), three renal ultrasounds (August 2007, June 2008, and August 2009), three pelvic ultrasounds (August 2007, June 2008, and September 2009), three aortic ultrasounds (August 2007, August 2008, and September 2009), and three LE Venous Dopplers (March 2007, May 2008, and May 2009).

On 4/19/2007, the family practitioner documented abdominal discomfort in his records.  There was no differential diagnosis, and no labs were ordered.  He ordered an ultrasound of the abdomen, pelvis, aorta, and a renal ultrasound.  Less than four months later, on 8/6/2007, there was similar documentation.

On 8/4/2008, abdominal pain was briefly documented, but there was again no differential diagnosis indicated and no labs were ordered.  The family practitioner ordered an ultrasound of the abdominal aorta.

On 8/13/2009, the family practitioner documented abdominal pain.  There was no differential diagnosis, and no labs were ordered.  The family practitioner only ordered an ultrasound of the abdomen and aorta.

On 11/17/2006, the patient presented with a complaint of chest pain and palpitations.  The family practitioner ordered an echocardiogram, but no EKG, and he didn’t order a chest x-ray, lab tests, or cardiac stress tests.  On 1/8/2007, the chest pains and palpitations were documented again.  There was a radiologist report on this patient for 7/16/2008 and 6/30/2010, which suggested a cardiac stress test should be done, but none of this was addressed by the family practitioner.

On 7/25/2006, the family practitioner documented a complaint of dizziness.  A carotid duplex was ordered.  On 1/14/2009, he documented the same complaint, but no further history.  A carotid duplex was ordered even though the patient had one ordered on 12/12/2007.

The Medical Board of California judged that the family practitioner’s conduct departed from the standard of care and was grossly negligent in the care and treatment of the patient because he misused ultrasounds to evaluate patient complaints and did not appropriately evaluate chest pain.  The family practitioner also failed to take an adequate history, work up a differential diagnosis, order labs, and appropriately evaluate dizziness. Patients with persistent or ongoing abdominal pain should have a CT scan or endoscopy.

For this case and others, the Medical Board of California placed the family practitioner on probation for 5 years and ordered that he complete a medical record-keeping course and an education course (at least 20 hours for 5 years) equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California

Date: February 2015

Specialty: Family Medicine, Internal Medicine

Symptom: Abdominal Pain, Dizziness, Chest Pain, Palpitations

Diagnosis: N/A

Medical Error: Unnecessary or excessive diagnostic tests, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF

On 7/15/2007, a 42-year-old male was taken by ambulance to the emergency department for chest pain.  The patient reported having left arm numbness and chest pain on a scale of 6 out of 10.  The patient had no prior history of heart disease, but his medical records indicated he reported that he had high blood pressure, smoked marijuana, and had similar episodes over the prior two weeks that included sweating, shortness of breath, and heart palpitations.  Hospitalist A evaluated and admitted the patient to the hospital in the telemetry unit for observation and a more complete medical work-up.  The patient did well overnight and showed no evidence of myocardial necrosis (heart attack) with normal electrocardiography (ECG) and troponin blood levels (cardiac damage marker in the blood).  Hospitalist A ordered a stress exercise echocardiogram (also known as a stress test).

A stress test was completed on 7/16/2007.  A cardiologist was only asked to interpret the stress test and not to provide a cardiology consultation or evaluate the patient.  The cardiologist interpreted the stress test approximately three hours after the test.  During the test, the patient showed good exercise tolerance, but he complained of chest pain.  Medical staff present during the test stopped it before completion due to the patient’s complaint of fatigue.  The test showed abnormal ECG’s, which suggested significant coronary artery disease.  The stress test also showed frequent premature ventricular contractions (PVC’s) and couplets (two in a row) in recovery, which was a possible marker for heart irritability from a blocked artery.  There was also stress-induced wall motion abnormality, which indicated that part of the heart was not getting enough blood flow due to a blocked coronary artery.

Despite these conditions, the cardiologist reviewed the stress test, and accompanying stress test worksheet, and found that there was no evidence of a heart problem in the patient.  The cardiologist dictated the following notes in the patient’s medical record: “This exercise echocardiographic study reveals no evidence for myocardial ischemia.  The patient did have chest discomfort and fatigue.  Note that frequent premature ventricular contraction was noted as described above.  Appropriate heart rate slowing did occur at one minute into recovery.  The patient achieved 117% of the predicted exercise capacity for age.”  At 6:08 p.m., the cardiologist wrote the following notes in the patient’s medical record: “EXE [exercise] (-) [negative] for ischemia. Freq. PVC’s in Recovery. Excellent exercise tolerance.”  The cardiologist determined that the patient’s stress test showed no heart problems or a blocked artery, when in fact, there were obvious signs of a blocked artery.

During the stress test, only an echocardiographic technician and nurse were present.  Despite the normal stress test results received from the cardiologist, the patient remained in the cardiac care unit overnight for continued monitoring.  The medical records for the patient indicated that he continued to complain to the nursing staff of chest pain, and he requested to speak with a doctor about the chest pain.  Also, the medical records reflected that the patient was afraid of being released from the hospital without knowing why he was having chest pain.  On the “Plan of Care” form in the patient’s medical records, the nursing staff wrote that the patient’s concerns were relayed to Hospitalist B on 7/17/2007.

On 7/17/2007 at 2 p.m., a physician assistant made the following handwritten note in the patient’s medical record: “stress test MNL [within normal limits], Lytes [electrolytes] OK. PVC’s during stress test OK.”  Hospitalist B ordered a lung test (spirometry) for the patient to determine if the chest pain was due to pulmonary issues, but the patient was discharged on 7/17/2007, before the spirometry tests were available, with instructions to see his primary care provider.  At no time did the cardiologist see the patient or review the medical chart from the patient’s admission date of 7/16/2007.

On 7/28/2007, the patient’s medical records, including from a coroner’s office, indicated that he was suffering from chest pains and called 911.  The patient was transported to the emergency department after suffering a heart attack.  The patient died in the emergency department. The subsequent autopsy listed the cause of death as “critical coronary artery stenosis due to coronary arterio and atherosclerosis.”  “Clinical history of hypertension” was also listed as another significant condition affecting the cause of death.

Investigators interviewed the cardiologist on 2/28/2012.  During this interview, the cardiologist admitted to making a mistake in how he read the patient’s stress test results.  He also admitted that he made a mistake in reading that there was no ischemia because it was in fact present.  Finally, the cardiologist denied that he needed to change his practice of supervision during stress tests.

The Medical Board of California judged that the cardiologist committed repeated negligent acts in his care and treatment of the patient and demonstrated a lack of knowledge and skill in his care and treatment of the patient given that he failed to identify an abnormality in the patient’s stress echocardiogram test results, which included a failure to recognize several high-risk indicators in the patient’s stress test and on the stress test worksheet.  Specifically, the high risk indicators were that the patient was a hospitalized patient in the cardiac care unit; was a marijuana smoker; was suffering from chest pain; developed chest pain rated a 4 out of 10 during the stress test; had a family history of coronary artery disease; developed PVC’s and couplets after the test; and developed ECG changes during exercise and during the recovery period.

For this case and another, the Medical Board of California issued a public reprimand and ordered that the cardiologist complete a clinical training or educational program equivalent to the Physician Assessment and Clinical Education Program (PACE) offered at the University of California, San Diego School of Medicine (Program) within 6 months after initial enrollment.

State: California

Date: December 2014

Specialty: Cardiology, Hospitalist

Symptom: Chest Pain, Numbness, Palpitations, Shortness of Breath, Weakness/Fatigue

Diagnosis: Acute Myocardial Infarction, Cardiovascular Disease

Medical Error: False negative

Significant Outcome: Death

Case Rating: 4

Link to Original Case File: Download PDF

On 3/12/2009, a 14-year-old patient came in with severe upper back, neck, and shoulder pain for 2 days.  There was no additional history to determine cause, such as injury, overuse, or home stress. The physical examination was largely illegible, but the neck exam was marked “abnormal” and did state that there was muscle spasm, but did not indicate where, and there was no assessment of neck range of motion.  This is critical to evaluate for severe conditions involving the neck region. On 4/8/2009, the patient injured her shoulder while playing softball. The medical records did not elaborate on the mechanism of injury. This information was important because had she fallen or been hit with a bat, an x-ray might have been indicated to evaluate for fracture.  While the medical assistant stated that the patient “pulled muscle in softball,” it was the family practitioner’s duty to determine for himself and document as clearly as possible what happened on the softball field.

The mostly illegible physical examination made a vague reference to limited range of motion of the right shoulder and some trapezius spasm.  There was no clarification of what movement was limited: flexion, extension, abduction, adduction, and internal or external rotation. There were also evocative tests to check the muscles of the shoulder, such as Hawkins test or the Neer test, which were not documented.  For a complete shoulder exam in the setting of a sports injury, there also should have been a visual inspection of the shoulder for swelling or deformities.

On 6/24/2009, the patient presented with severely painful menstrual periods as well as increased bleeding, fatigue, and dizziness.  There was no menstrual history otherwise documented in terms of age of menarche, timing/frequency of menstruation, days of bleeding, changes in the amount of bleeding, and if she had tried any medication to treat these symptoms.  There was also no sexual history to determine risk of pregnancy. While in girls who have not been sexually active, it is usually appropriate to defer a vaginal speculum exam, but certainly an external abdominal and pelvic exam should have been documented to determine where her pain was located, and to ensure other serious conditions, such as hernia or appendicitis are not present.  In addition, since the history suggested symptomatic blood loss, a complete blood count lab test was indicated to complete vital signs at that visit. Instead, the family practitioner stated “(checkmark) HBG next visit” without specifying how long that would be.

On 9/21/2009, the patient presented with a complaint of right abdominal pain.  The history was illegible but there was no clarification of where the pain was, when it started, or its severity.  This was important because the pain could have been from the appendix and immediate intervention would be critical.  In addition, there was no comment on bowel patterns which would determine if the patient was having any constipation, which could be a side effect from the opiates he prescribed.  Incomplete vitals and the lack of a legible abdominal examination made this evaluation even more problematic. On 6/22/2011, the patient was seen for headaches. There was no additional history taken.  Although her chart indicated that she was seen by “children’s” for severe migraine, there appeared to have been no effort to obtain a pediatric neurology consultation report and each time a migraine sufferer presents to the clinic with a headache, a history should be taken to ensure the headache is not progressing or is indicative of other, serious underlying pathology.

The review of systems on this visit was positive for multiple concerning symptoms: chest pain, palpitations, insomnia, sore throat, cough, shortness of breath, numbness, and headaches.  Further questioning should have been done and documented to try and determine the basis of this constellation of symptoms. While anxiety was a reasonable deduction, it was also possible she was withdrawing from the opiates she was taking.  The only documented vital sign was a blood pressure of 98/58. A patient presenting for evaluation of shortness of breath and cough should have a documented temperature, respiratory rate, and oxygen saturation to help determine if a high-risk condition existed.

On 8/2/2011, the patient was diagnosed with depression and anxiety.  There was no history justifying those diagnoses, which are typically made during an interview.  The family practitioner committed an extreme departure from the standard of care for failure to fully evaluate multiple, potentially serious, patient concerns with complete history taking, appropriate physical exam, and analytic reasoning.  On 8/2/2011, at a physical exam, the patient was diagnosed with endometriosis. There was no history documented on the History and Physical form indicating the patient had pelvic pain. The physical exam was completely normal, and the genitalia exam was deferred.  Since diagnostic imaging is rarely helpful in this condition, the next step, if truly suspected, would be a specialty consultation with a gynecologist to consider surgery to diagnose endometriosis. The patient was also diagnosed with rheumatoid arthritis at the 8/2/2011 physical exam appointment.  There was no history taken that would suggest this patient had the typical morning stiffness in the hands and other joints and since the physical exam was normal there was no objective evidence of arthritis. This patient was also diagnosed with hypothyroidism. The family practitioner made this diagnosis without the requisite lab tests.  Later, when he finally did order a TSH, it was normal. The patient never had hypothyroidism.

On 8/10/2011, the patient followed up and complained of fatigue, chest pain, and back pain.  The physical exam was completely normal and again, the patient was diagnosed with rheumatoid arthritis, which can only be diagnosed with lab tests that the family practitioner failed to order.  A number of diagnostic lab tests were ordered, including a rheumatoid factor and sedimentation rate. The rheumatoid factor was slightly elevated at 16 and the sedimentation rate was 2. The sedimentation rate was consistent with no active inflammation and the low rheumatoid factors did not diagnose any condition.  When the patient was referred to the pediatric rheumatologist on 10/14/2011, his opinion was that this patient did not have any evidence of rheumatoid arthritis or any other rheumatologic disorder. The rheumatologist also did not find evidence for fibromyalgia. Thus, the pediatric rheumatologist indicated that the mild rheumatoid factors abnormality was “irrelevant.”  Despite this specialist consultation, the diagnosis of rheumatoid arthritis persisted in his progress note on 11/21/2011. The family practitioner noted that he reviewed the rheumatology consultation with the patient and seemed to disagree with the rheumatologist’s opinion given that he stated “she has high RA factor.” He continued to both diagnose rheumatoid arthritis and prescribe opiate pain medications in direct contradiction to the pediatric rheumatologist who recommended a pain management program and specific avoidances of opiates and benzodiazepines.

Again on 12/12/2011, the family practitioner diagnosed both rheumatoid arthritis and fibromyalgia as justification for his opiate prescriptions.  This was treatment for conditions the patient never had. The family practitioner demonstrated incompetence by failing to gather appropriate history and assimilate physical exam findings and interpret lab tests appropriately that resulted in misdiagnosis of endometriosis, rheumatoid arthritis, and hypothyroidism.

For this allegation and others, the Medical Board of California issued the surrender of the family practitioner’s license.

State: California

Date: September 2014

Specialty: Family Medicine, Internal Medicine

Symptom: Back Pain, Cough, Dizziness, Abnormal Vaginal Bleeding, Headache, Numbness, Abdominal Pain, Chest Pain, Head/Neck Pain, Joint Pain, Palpitations, Shortness of Breath, Weakness/Fatigue

Diagnosis: N/A

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

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF