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Florida – Ophthalmology – Persistent Pain And Inflammation In The Right Eye Following Cataract Surgery
On 12/4/2013, a 78-year-old female presented to an ophthalmologist for phacoemulsification with posterior chamber implant (“cataract surgery”) on her right eye.
During the cataract surgery, the patient experienced a posterior capsule tear, a known complication and an accepted risk associated with cataract surgeries.
On 2/3/2014, the patient presented to the ophthalmologist for an examination, and the ophthalmologist noted inflammation in the patient’s operative eye.
On 3/27/2014, the patient presented to the ophthalmologist for an examination, and the ophthalmologist noted inflammation in the patient’s operative eye.
On 4/8/2014, the patient presented to the ophthalmologist for an examination, and the ophthalmologist noted that the patient experienced post-operative chronic iritis in her operative eye.
On 5/6/2014, the patient presented to the ophthalmologist for a follow-up examination of her operative eye.
On 8/14/2014, the patient presented to the ophthalmologist for a follow-up examination of her operative eye.
On 9/18/2014, the patient presented to the ophthalmologist and reported throbbing pain in her operative eye.
Despite knowing that the patient experienced a complicated cataract surgery, followed by persistent inflammation in her operative eye, the ophthalmologist did not perform a dilated examination until 9/18/2014.
Despite knowing the patient experienced a complicated cataract surgery, followed by persistent inflammation in her operative eye, the ophthalmologist did not refer her to a retina specialist.
The Board judged the ophthalmologist’s conduct to be below the minimum standard of competence given his failure to perform a dilated examination on the patient’s operative eye to investigate the causes of persistent post-operative inflammation within a reasonable time after the cataract surgery. The ophthalmologist also failed to refer the patient to a retina specialist to investigate the causes of persistent post-operative inflammation within a reasonable time after cataract surgery.
The Board ordered that the ophthalmologist pay a fine of $2,500 against his license and that the ophthalmologist pay reimbursement costs for the case for a minimum of $4,634.56 but not to exceed $6.634.56. The Board also ordered that the ophthalmologist complete five hours of continuing medical education in post-operative care and complete one hour of continuing medical education in “Risk Management.”
State: Florida
Date: November 2017
Specialty: Ophthalmology
Symptom: Head/Neck Pain, Swelling
Diagnosis: Post-operative/Operative Complication, Ocular Disease
Medical Error: Failure to examine or evaluate patient properly, Referral failure to hospital or specialist
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Pediatrics – Deep Laceration Of The Right Knee Treated With Debridement, Irrigation, And Suturing
On 12/7/2011, an 8-year-old male presented to a medical emergency department with a deep laceration to his right knee. The laceration was a full thickness cut with visualization of the capsule. An x-ray revealed air in the knee joint.
A pediatrician examined the patient’s knee and performed debridement, cleaning by irrigation, and suturing of the laceration. Bacitracin and dressing were applied to the patient’s knee.
On 12/10/2011, the patient returned to the emergency department with complaints of right knee swelling, redness, and pain. The patient was admitted to the pediatric floor.
Further examination revealed septic arthritis in the patient’s right knee, which required two operations and the introduction of a PICC line for long-term antibiotic therapy. The patient sustained cartilage damage as a result of the septic arthritis and suffered from significant knee pain.
The Board judged the pediatrician’s conduct to be below the minimal standard of competence given that he failed to refer the patient to an orthopedic surgeon and to fully wash out the patient’s joint by performing an open debridement under anesthesia.
The Board issued a letter of concern against the pediatrician’s license. The Board ordered the pediatrician to pay a fine of $10,000 against his license and pay reimbursement costs at a minimum of $5,496.59 and not to exceed $7,496.59. The Board also ordered that the pediatrician complete ten hours continuing medical education in pediatric orthopedic diagnosis and treatment and complete five hours of continuing medical education in “risk management.”
State: Florida
Date: June 2017
Specialty: Pediatrics, Orthopedic Surgery
Symptom: Joint Pain, Swelling
Diagnosis: Trauma Injury, Septic Arthritis
Medical Error: Improper treatment, Referral failure to hospital or specialist
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 4
Link to Original Case File: Download PDF
Florida – Pain Management – Infection Of Left Prosthetic Knee Following Injections Of Zeel And Traumeel With Bupivacaine
On 9/15/2011, a 57-year-old male presented to a pain management specialist with complaints of knee pain in his prosthetic knees.
On 10/13/2011, the pain management specialist established a treatment plan to obtain x-rays of the patient’s knees and refer him to an orthopedic surgeon for evaluation of his prosthetic knees.
The pain management specialist failed to review, or document reviewing, x-rays of the patient’s prosthetic knees. He also failed to refer the patient to an orthopedic surgeon for evaluation of his knee pain, per his treatment plan.
On 2/2/2012, the pain management specialist injected Zeel and Traumeel (both homeopathic products) with bupivacaine into the patient’s prosthetic left knee.
The pain management specialist did not create or maintain records documenting an examination of the patient’s left knee for the 2/2/2012 appointment.
On 2/8/2012, the pain management specialist performed a second injection of Zeel and Traumeel with bupivacaine into the patient’s prosthetic left knee. He did not create or maintain records documenting an examination of the patient’s left knee for the 2/8/2012 appointment.
Shortly after the second injection, the patient’s left knee began to swell, and on 2/21/2012, he presented to an orthopedic institute with complaints of pain, swelling, and redness.
An orthopedic surgeon admitted the patient to a hospital for further evaluation. At the hospital, the patient was diagnosed with acutely infected left total knee arthroplasty and, on 2/25/2012, underwent surgery to remove part of the left knee prosthesis, insert an antibiotic disc and PICC line, and begin IV antibiotics.
The Medical Board of Florida judged the pain management specialists conduct to be below the minimal standard of competence given that he should not have injected homeopathic substances into the patient’s prosthetic left knee and he did not refer the patient to an orthopedic surgeon for evaluation of his left knee pain.
It was requested that the Medical Board of Florida order one or more of the following penalties for the pain management specialist: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Medical Board of Florida deemed appropriate.
State: Florida
Date: April 2017
Specialty: Pain Management, Anesthesiology, Orthopedic Surgery
Symptom: Joint Pain, Swelling
Diagnosis: Procedural Site Infection
Medical Error: Unnecessary or excessive treatment or surgery, Failure to examine or evaluate patient properly, Referral failure to hospital or specialist, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Kansas – Physician Assistant – Lovenox Prescribed For DVT In A Patient With A History Of GI Bleeding
On 11/19/2015, a patient presented to a family care clinic with complaints of swelling and pain in the right lower extremity (“RLE”).
The patient was seen by the APRN who documented the patient’s history of GI bleeding, noting the patient had experienced a RLE deep vein thrombosis (“DVT”) and pulmonary embolism (“PE”) on October 2015, that had been treated with an IVC filter in a medical center.
The APRN further documented in the patient’s chart, “No [sic] on anticoagulants due to GI Bleed,” and “Recent [history] GI bleed.”
The patient was referred to cardiology for the management of his anticoagulation. He was to follow up on the morning of 11/20/2015 to have a complete blood count (“CBC”) drawn.
On 11/20/2015, the patient presented to a physician assistant with right leg and foot swelling with new onset pain rated a 1/10. The physician assistant did not document a patient history and did not review the APRN’s notes from 11/19/2015. The physician assistant diagnosed the patient with DVT of the right popliteal vein and mild anemia. The physician assistant improperly prescribed Lovenox 60 mg SQ twice a day for one week with a follow-up to confirm dissolution of the clot.
On 11/23/2015, the patient awoke during the night with chest pain and was transported via ambulance to the emergency department where it was determined the patient had a GI bleed. The patient’s hemoglobin (“HGB”) dropped abnormally low to 7.7, and his hematocrit (“HCT”) was also abnormally low at 27.4%.
The physician assistant’s response, received by the Board on 3/29/2016, noted, “There was no indication in the note from the previous day, nor in any clinic note that he was not a candidate for anticoagulation therapy.” However, the original notes received by the Board on 10/6/2016 from the hospital indicated that the patient had a history of GI bleed and no anticoagulants should have been prescribed.
The Board judged the physician assistant’s conduct to be below the minimum standard of competence given his inappropriate prescribing of Lovenox.
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, Emergency Medicine, Internal Medicine
Symptom: Blood in Stool, Extremity Pain, Swelling
Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Deep Vein Thrombosis/Intracardiac Thrombus, Pulmonary Embolism
Medical Error: Improper medication management, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
California – Internal Medicine – Smart-Lipo For Enlarged Male Chest Results In Asymmetry
On 3/9/2013, a 63-year-old male (6’2” tall who weighed 244.5 pounds) went to an internist’s clinic for a Smart-Lipo consultation for his enlarged male chest. On the “Pre-Procedural Evaluation for Smart-Lipo” form, the consultant noted that the patient could benefit from Smart-Lipo to the waist, male chest, and lower abdomen. The patient chose only to have the procedure done to his chest.
On 3/14/2013, the patient underwent pre-operative procedures and then Smart-Lipo surgery. The surgery proceeded without any complications, but the medical records were difficult to read. According to the patient, he was told it could take 6 months to see results.
On 3/22/2013, the patient returned to the internist’s clinic for his post-operative follow-up. During this appointment, the patient expressed concerns that the swelling was more than he expected. On 5/3/2013, the patient returned for another follow-up visit. During this visit, he indicated that he was not happy with his results as there was asymmetry between the left and right sides of his chest (the left side was larger than the right side).
On 9/23/2013, during the patient’s next follow-up appointment, it was suggested that revision surgery was needed on his left breast. On 10/10/2013, the internist performed revision Smart-Lipo to the patient’s left breast. The patient never returned to the internist’s clinic.
The patient complained to the Board that he was not satisfied with the results. After 6 months post-surgery, he continued to see problems with the left side of his chest. He asked for a refund from the internist’s clinic, but it was denied.
The Medical Board of California judged that the internist’s conduct departed from the standard of care because she failed to maintain adequate and accurate medical records, lacked sufficient skill and knowledge to perform Smart-Lipo safely, and failed to recognize the signs and symptoms of gynecomastia as a possible source of the patient’s enlarged breast tissues.
For this case and others, the Medical Board of California placed the internist on probation for 4 years and ordered the internist to complete a professionalism program (ethics course), a medical record keeping course, an education course (at least 25 hours per year for eat year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine. The internist was assigned a monitor for practice and billing, and she was prohibited from practicing or attempting to perform liposuction or laser skin treatments. The internist was also prohibited from supervising physician assistants.
State: California
Date: April 2017
Specialty: Internal Medicine, Plastic Surgery
Symptom: Swelling
Diagnosis: N/A
Medical Error: Failure to examine or evaluate patient properly, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Washington – Physician Assistant – Groin Rash, Swelling, And Hard Left Testicle Found On Infant
On 1/3/2015, a seven-month-old patient was brought to an urgent care facility where he was seen by a physician assistant. His history included over several months of groin rash that was being treated with steroid cream. The patient’s mother reported that the patient’s left testicle was hard. Over the past two days, his symptoms had worsened. The physician assistant examined the patient and found a rash and swelling at the scrotum only. He diagnosed the patient with a diaper rash.
On 1/4/2015, the patient’s grandparents brought the patient to the emergency department, where he was examined by a second provider. The patient’s grandparents reported that the patient seemed uncomfortable and that his left scrotum appeared red, swollen, and firm. An ultrasound found the patient’s left testicle with decreased blood flow. The patient was transferred to another facility and testicular torsion was confirmed. The patient underwent emergency surgery where his testicle was found nonviable and removed.
The physician assistant did not consider testicular torsion in the differential diagnosis and failed to order an ultrasound to rule out this condition.
The Commission stipulated the physician assistant reimburse costs to the Commission, complete a continuing medical education course in assessment and diagnosis of acute scrotal conditions, and submit a paper of no less than one thousand words, with references, on the subject of acute scrotal conditions.
State: Washington
Date: April 2017
Specialty: Physician Assistant, Pediatrics, Urology
Diagnosis: Testicular Torsion
Medical Error: Failure to order appropriate diagnostic test
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 3
Link to Original Case File: Download PDF
Florida – Dermatology – Pathologist Performs Botox And Radiesse Injections Resulting In Complications
On 6/20/2014, a pathologist performed Botox injection to a patient’s forehead and Radiesse injections to her cheeks in the pathologist’s home.
Three days later, on 6/23/2014, the patient complained of severe swelling and redness at the injection sites on her cheeks.
The pathologist advised the patient to use a cold compress, to apply hydrocortisone cream, to take Claritin and ibuprofen, and to return for follow up in two days.
Shortly thereafter, the patient began to experience more swelling and draining at the injection sites.
On 6/26/2014, the patient presented to the pathologist for a follow-up appointment. The pathologist documented that the patient’s swelling had subsided and that her pain was mainly relieved. The patient was instructed to continue to take Claritin and ibuprofen for two weeks.
On 7/10/2015, the patient presented to a physician with complaints of pain, swelling, and drainage at the injection sites. The physician treated the patient for abscesses that had occurred at the injection sites.
The Medical Board of Florida judged the pathologists conduct to be below the minimal standard of competence given that the pathologist did not record the lot number of the Radiesse in the patient’s chart. Also, the pathologist placed the injection too close to the patient’s eye area. The pathologist placed the injections too superficially in the patient’s skin. The pathologist incorrectly diagnosed the patient with a hypersensitivity reaction.
The Medical Board of Florida issued a letter of concern against the pathologist’s license. The Medical Board of Florida ordered that the pathologist pay a fine of $5,000 against her license and pay reimbursement costs for the case at a minimum of $5,175.43 and not to exceed $7,175.43. The Medical Board of Florida also ordered that the pathologist complete a records course within one year of the final order, complete ten hours of continuing medical education in cosmetic procedures, and complete five hours of continuing medical education in “risk management.”
State: Florida
Date: March 2017
Specialty: Dermatology, Pathology
Symptom: Dermatological Abnormality, Swelling, Wound Drainage
Diagnosis: Dermatological Issues
Medical Error: Diagnostic error, Lack of proper documentation, Procedural error
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
California – Orthopedic Surgery – MRSA Bacteremia With Swelling And Erythema Of The Left Knee
On 6/11/2014, a 20-year-old male at that time presented to an emergency department with left knee pain and swelling of the left leg. On 6/15/2014, Orthopedic Surgeon A provided an orthopedic consultation, which was requested by the admitting physician to rule out infection in the knee. In his exam, Orthopedic Surgeon A noted swelling around the left leg area, satisfactory circulation of the left lower extremity, a mildly tender left leg, and definite tenderness over the tibia. Diffuse tenderness over the left knee and no obvious swelling were noted. The range of movement for the left knee was painful from full extension to beyond 90 degrees; otherwise, the knee was stable.
Orthopedic Surgeon A reviewed an x-ray of the left knee finding no obvious swelling and an essentially normal exam. No complaint of an acute infection was found on the tibia or knee by the orthopedic surgeon. Orthopedic Surgeon A’s impression was a healed fracture of the left tibia with tibial nailing with positive blood culture for infection. Orthopedic Surgeon A’s aspiration of the left knee did not show any pus and very little serosanguinous fluid was aspirated, the fluid was sent for culture and sensitivity. Orthopedic Surgeon A did not feel the patient needed aggressive orthopedic treatment, and his plan was for the patient to be treated for infection as per the infectious disease specialist’s recommendations.
On 6/17/2014, an internal medicine physician noted that the patient had severe sepsis due to methicillin-resistant Staphylococcus aureus bacteremia. The patient was receiving IV vancomycin; however, he continued to have persistent bacteremia, which was suspected to be secondary to the knee. The internal medicine physician attempted to have Orthopedic Surgeon A evaluate the patient on that day; however, Orthopedic Surgeon A felt there was no needed to see the patient on 6/17/2014. The internal medicine physician then requested a second opinion from Orthopedic Surgeon B.
On 6/17/2014, the patient was examined by Orthopedic Surgeon B. Upon his exam, Orthopedic Surgeon B noted a circumferential anterior cellulitis type of finding on the anterior left knee and that the skin appeared to be indurated in this region. Orthopedic Surgeon B’s impression was left knee infection, possible prepatellar bursitis. Orthopedic Surgeon B was not convinced that the aspiration performed by Orthopedic Surgeon A was in the knee joint as he saw the location of the aspiration was directly through the red prepatellar bursa region. Orthopedic Surgeon B found that the patient would likely need surgery for treatment of infection. However, the treatment would depend on whether the patient had prepatellar bursitis or septic knee. Orthopedic Surgeon B noted that he called Orthopedic Surgeon A on 6/17/2014 in an attempt to discuss his findings. However, Orthopedic Surgeon A did not feel the need to follow up with the patient that day.
On 6/18/2014, Orthopedic Surgeon A examined the patient for the second time. Orthopedic Surgeon A noted redness over the anterior surface of the knee. He did not find any evidence of prepatellar bursitis except for redness and noted that there was diffuse tenderness around the left knee. Orthopedic Surgeon A reviewed an MRI of the knee, finding synovitis with effusion. Orthopedic Surgeon A aspirated the knee again, obtaining 2 ml of bloody fluid and finding no evidence of pus. Based on the MRI and his evaluation, Orthopedic Surgeon A’s impression was that the patient had hypertrophic synovitis with effusion of the left knee per MRI. Orthopedic Surgeon A’s plan was for the patient to be treated with IV antibiotics as recommended by the infectious disease specialist until the infection was under control. Orthopedic Surgeon A did not recommend surgery of the left knee.
Orthopedic Surgeon B also reviewed the MRI of the left knee and found a large effusion with evidence of soft tissue edema. Orthopedic Surgeon B noticed a clear abscess in subcutaneous tissue and loculated fluid in the knee joint. Orthopedic Surgeon B’s impression was severe sepsis due to probable left septic knee and possible secondary cellulitis over the left knee. Accordingly, on 6/18/2014, the patient underwent a left knee arthroscopy, incision and drainage with lavage of the left knee joint; left knee arthroscopy; synovectomy; left knee arthroscopy and synovial biopsy; left knee prepatellar bursa incision and drainage; and left knee proximal tibia hardware removal of one single locking bolt of tibia intramedullary nail.
Orthopedic Surgeon B’s findings included positive gross pus in the prepatellar bursa consistent with prepatellar bursa and abscess of 150 ml of gross pus; positive gross pus and left knee joint synovitis; and medial proximal locking bolt of tibia intramedullary nail exposed in the prepatellar bursa region.
The Board reprimanded Orthopedic Surgeon A and ordered him to complete 20 hours of a continuing medical education course in reading and interpreting MRI’s.
State: California
Date: January 2017
Specialty: Orthopedic Surgery, Internal Medicine
Symptom: Joint Pain, Swelling
Diagnosis: Septic Arthritis, MRSA, Sepsis
Medical Error: Diagnostic error
Significant Outcome: N/A
Case Rating: 4
Link to Original Case File: Download PDF
Florida – General Surgery – Lump And Pain After Procedure To Strip Greater Saphenous Vein And Ligate Saphenofemoral Junction
On 9/9/2011, a general surgeon performed a greater saphenous vein stripping, a ligation of the saphenofemoral junction, and phlebectomies on a patient’s right leg.
On 9/12/2011, the third post-operative day, the patient reported pain and redness.
The next day, on 9/13/2011, the patient called the general surgeon’s office and complained of throbbing pain in her right leg and groin. The patient was instructed to use a heating pad, to elevate her leg as much as possible, and to call if symptoms escalate.
The next day, on 9/14/2011, at a follow-up appointment with the general surgeon, the patient reported increased pain secondary to a hematoma. The patient was instructed to follow up in one week.
Six days later, on 9/19/2011. The patient called the general surgeon’s and complained of increased pain in her right leg and a lump in her right groin area. The patient was instructed to go to a radiology center for a stat right leg ultrasound.
The patient presented for a venogram, which revealed total occlusion of the right common femoral vein with extravasation.
The patient was transferred to a medical center on 9/23/2011. A physician performed a right groin evacuation of the hematoma and exploration of the right common femoral vein. The physician found that during the original surgery, the general surgeon had ligated and transected the common femoral vein instead of the greater saphenous vein.
As a result of the injury, the patient continues to experience pain and swelling to her right leg.
The Medical Board of Florida judged the general surgeon’s conduct to be below the minimum standard of competence given that he failed to clearly identify the saphenofemoral junction and then ligate, transect, and strip the greater saphenous vein. The general surgeon also failed to further investigate the patient’s pain and hematoma at the time of her complaints, including ordering a venous ultrasound of the leg. The general surgeon did not correctly identify and ligate the greater saphenous vein. Instead, he ligated and transected the common femoral vein. The general surgeon did not adequately investigate and evaluate the patient’s post-operative pain and hematoma. Instead, he waited seven days before advising the patient to obtain a venous ultrasound.
The Medical Board of Florida issued a letter of concern against the general surgeon’s license. The Medical Board of Florida ordered that the general surgeon pay a fine of $10,000 against his license and pay reimbursement costs for the case at a minimum of $8,070.79 and not to exceed $10,070.79. The Medical Board of Florida also ordered that the general surgeon complete a medical records course, complete five hours of continuing medical education in vascular surgery, and complete five hours of continuing medical education in “risk management.”
State: Florida
Date: November 2016
Specialty: General Surgery
Symptom: Pelvic/Groin Pain, Mass (Breast Mass, Lump, etc.), Extremity Pain, Swelling
Diagnosis: Post-operative/Operative Complication, Cardiovascular Disease
Medical Error: Wrong site procedure, Delay in proper treatment, Failure to order appropriate diagnostic test
Significant Outcome: N/A
Case Rating: 4
Link to Original Case File: Download PDF
California – Urology – Swollen Right Testicle With A History Of Left Testicle Removed
In 1990, a patient had his left testicle surgically removed.
On 5/27/2011, the patient first presented to a urologist complaining of swelling in the right hemiscrotum that had lasted for several weeks. The patient provided a medical history which was recorded by the urologist as follows:
“He complains of a swollen testicle on the right. The symptoms have been present several weeks. He states there was no history of trauma prior to the swelling. There is tenderness but no pain. The mas [sic] has been getting larger. The swelling gets worse with sitting. No dysuria noted. He has no frequency. No hematuria is present. He has no nocturia. H/O L cord lipoma x2/L orchiectomy 1990.”
The urologist ordered an ultrasound for the patient. The urologist claims that he was never made aware, until 7/18/2013, that the patient had a liposarcoma in 1990.
However, on 6/16/2011, an ultrasound of the patient was performed at a community hospital. The ultrasound report stated, “Patient with history of spermatic cord liposarcoma.” The ultrasound report was provided to the urologist.
On 6/21/2011, the urologist again saw the patient. The medical history generated by the urologist for this visit is identical to the medical history of 5/27/2011, stating:
“He complains of a swollen testicle on the right. The symptoms have been present several weeks. He states there was no history of trauma prior to the swelling. There is tenderness but no pain. The mas [sic] has been getting larger. The swelling gets worse with sitting. No dysuria noted. He has no frequency. No hematuria is present. He has no nocturia. H/O L cord lipoma x2/L orchiectomy 1990.”
The urologist also wrote in the medical record for the 6/21/2011 visit that the patient’s “left testicle is normal to palpation. No masses or tenderness noted. Size normal.”
On 12/15/2011, the urologist again saw the patient. Again, the medical history generated by the urologist is identical to the medical history of 5/27/2011, stating:
“He complains of a swollen testicle on the right. The symptoms have been present several weeks. He states there was no history of trauma prior to the swelling. There is tenderness but no pain. The mas [sic] has been getting larger. The swelling gets worse with sitting. No dysuria noted. He has no frequency. No hematuria is present. He has no nocturia. H/O L cord lipoma x2/L orchiectomy 1990.”
The urologist also wrote in the medical record for the 12/15/2011 visit that “both testicles appear to be of normal size and location.”
On 12/6/2012, the urologist saw the patient. The urologist noted an elevated prostate-specific antigen (PSA) but elected a conservative treatment plan, which consisted of observing the patient without ordering a prostate biopsy.
The urologist also wrote in the medical record for the 12/6/2012 visit that “both testicles are normal to palpation.”
On 1/17/2013, the urologist saw the patient. Even though the visit was some sixteen months after the first visit, the medical history generated by the urologist appears to be “cut-and-pasted” from the medical history of 5/27/2011, stating:
“He complains of a swollen testicle on the right. The symptoms have been present several weeks. He states there was no history of trauma prior to the swelling. There is tenderness but no pain.”
On 7/18/2013, the urologist saw the patient. The urologist noted a presence of a moderate sized lipoma in the left inguinal region. Additionally, the urologist noted for the first time in the medical records for the patient a history of liposarcoma being resected in 1990.
The urologist also wrote in the medical record for the 7/18/2013 visit that “Both testicles appear to be of normal size and location.”
Again, part of the medical history generated by the urologist for the 7/18/2013 visit is identical to the prior medical history of 5/27/2011 stating:
“He complains of a swollen testicle on the right. The symptoms have been present several weeks. He states there was no history of trauma prior to the swelling. There is tenderness but no pain.”
The remainder of the medical history continued with the following:
“There has been no change in size since it was first discovered. The swelling gets worse with sitting. No dysuria noted. He has no frequency. No hematuria is present. Patient states that there is occasional urinary hesitancy. He has no nocturia. H/O L cord liposarcoma x2/L orchiectomy 1990.”
The urologist again elected to observe the patient and a follow-up appointment was ordered.
On 1/21/2014, the urologist met with the patient. Medical records make no mention of any examination of the patient’s genitalia, groin or inguinal canals, and the records make no mention regarding the presence, absence, or change of the left inguinal lipoma.
The medical history generated by the urologist for the 1/21/2014 visit is identical to the prior medical history of 7/18/2013 and stated:
“He complains of a swollen testicle on the right. The symptoms have been present several weeks. He states there was no history of trauma prior to the swelling. There is tenderness but no pain. There has been no change in size since it was first discovered. The swelling gets worse with sitting. No dysuria noted. He has no frequency. No hematuria is present. Patient states that there is occasional urinary hesitancy. He has no nocturia. H/O L cord lipoma x2/L orchiectomy 1990.”
On 6/6/2014, the patient was examined at Stanford University after being referred by the urologist due to complaints of a large, growing, and symptomatic left inguinal mass noted by the patient’s primary care physician.
Ultimately, on 7/23/2014, the patient underwent a left hemiscrotectomy and pelvic dissection for a mass abutting the urethra and corporeal bodies of the penis, extending to the lateral bulb of the urethra and anterior above the inguinal ligament over the symphysis.
Pathology revealed this mass to be a large well-differentiated liposarcoma measuring 23 centimeters by 15 centimeters by 5.5 centimeters.
The Board judged the urologist’s conduct as having fallen below the standard of care given failure to address the mass in the left groin with imaging, biopsy, excision, or referral to a specialist in the field, and given misrepresentation that he had completed an examination of the left testicle of the patient when in fact he had not done so.
A hearing was conducted. At the conclusion of the hearing, the Board placed the urologist on probation for five years with stipulations for the urologist to complete a professionalism program and a clinical training program equivalent to the Physician Assessment and Clinical Education Program.
State: California
Date: November 2016
Specialty: Urology
Symptom: Mass (Breast Mass, Lump, etc.), Swelling
Diagnosis: Cancer
Medical Error: Diagnostic error, Failure to examine or evaluate patient properly, Underestimation of likelihood or severity, Referral failure to hospital or specialist, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF