Found 13 Results Sorted by Case Date
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Vermont – Family Practice – Oversight In Anorexia Nervosa Monitoring



A patient was treated by a family practitioner from May 2012 to September 2012.

On the first office visit, the patient presented with symptoms and behaviors that met the DSM-IV criteria of anorexia nervosa, as well as the National Institute for Mental Health criteria of Pediatric Acute Neuropsychiatric Syndrome (PANS).  The patient’s medical records from the patient’s prior primary care physician included a diagnosis of anorexia nervosa and a prior recommendation for inpatient mental health treatment for anorexia.

The family practitioner made the following diagnoses:  systemic inflammatory syndrome with multi-systemic symptoms and marked neuropsychiatric dysfunction with probable underlying infectious triggers; PANS (Pediatric Acute Neuropsychiatric Syndrome); and probable PITANDs (Pediatric Infection-Triggered Autoimmune Neuropsychiatric Disorders).  Anorexia nervosa was not documented as a primary or differential diagnosis.  The family practitioner indicated that he considered the possibility of a purely behavioral syndrome like anorexia nervosa, but felt that the patient’s anorexia was “part of a more complex multi-system picture.”

The family practitioner based his diagnosis on the patient’s history and symptoms meeting the diagnostic criteria for PANS, testing positive to three infectious agents, and an initial response positive response to PITANDs treatment, in addition to a lack of positive response to anorexia nervosa focused management with the patient’s prior primary care physician and other consultants.

The family practitioner saw the patient on three occasions over a four month period, which the Board believes is inadequate for management of anorexia for an adolescent.  The family practitioner relied on his nurse to call the patient on weekly updates and weight checks.

In addition to three office visits, the family practitioner’s treatment included ordering numerous blood tests, and the prescribing of medications, antibiotics, herbal supplements, and vitamins for the infection etiologies and the inflammatory conditions.  However, he did not prescribe any medications for the treatment of anorexia nervosa. While the family practitioner believed that the patient was being treated by his primary care physician, this was not confirmed with any other provider, and the family practitioner did not communicate directly with any other provider beyond sending his initial office visit note and lab results to the patient’s primary care physician.

The Board judged the family practitioner’s medical records and communication with the patient’s primary care physician concerning his treatment of the patient were inadequate. The family practitioner’s office notes did not document past surgical and family history, temperature, height, BMI calculation, and growth curve charting.

Based on review of the family practitioner’s medical records concerning his treatment of the patient and the documentation of his communication with the patient’s parents, it appears that the family practitioner did not clearly explain his role in the patient’s care to the patient’s parents until the end of his treatment.  Is it possible that the patient’s parents believed that the family practitioner had taken over the role as the primary care physician and was actively managing the patient’s care.

The family practitioner’s position was that he believed that he was participating in the care of the patient in the role as a consultant to his primary care physician and that the patient’s primary care physician was concurrently monitoring the patient.  With the exception of the provision of his initial office note and lab results, the family practitioner did not communicate with the patient’s primary care provider during the course of his treatment.  After sending his initial note and lab results, the family practitioner did not communicate with the patient’s primary care provider or any other medical professionals until the patient had an acute worsening of the condition on 9/13/2012.

The Board judged that the family practitioner failed to appropriately monitor, manage, and maintain comprehensive medical records on a juvenile patient with a severe eating disorder.

The Board ordered that the family practitioner be reprimanded, complete one hour of continuing medical education on cognitive bias, and that he shall only practice medicine in a structured, group setting for a period of three years.

State: Vermont


Date: September 2017


Specialty: Family Medicine, Psychiatry


Symptom: Weight Loss


Diagnosis: Psychiatric Disorder


Medical Error: Improper treatment, Failure of communication with other providers, Failure of communication with patient or patient relations, Failure to properly monitor patient, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Gastroenterology – Endoscopy In High Risk Patient With Esophageal Scleroderma Results In Complications



A 69-year-old male with diffuse systemic sclerosis, interstitial lung disease, end stage renal disease on hemodialysis, anemia, hypertension, hypoalbuminemia, secondary hypothyroidism, and gastric antral vascular ectasia (“GAVE”) had been referred to a gastroenterology clinic for evaluation of recurrent problems with weight loss and dysphagia.  It was assumed that the patient’s disease had progressed to esophageal scleroderma and that a percutaneous endoscopic gastrostomy (“PEG”) would be necessary to bypass his esophagus and would allow him to take in adequate nutrition without swallowing.  The patient was referred to the gastroenterology clinic for evaluation and a PEG.

On 6/25/2012, the gastroenterologist ordered a PEG, and she scheduled an esophagogastroduodenoscopy (“EGD” or upper endoscopy) and esophageal manometry for the afternoon of 6/25/2012, both elective, non-emergent diagnostic procedures, scheduled to be done on an outpatient basis.  On 6/23/2012 or 6/24/2012, the patient had been discharged from the hospital on antibiotics with home oxygen administration after treatment for aspiration pneumonia.

The gastroenterologist performed a pre-endoscopy history and physical examination in the early afternoon of 6/25/2012 and noted that the patient had active diffuse scleroderma complicated by renal crisis, diffuse systemic sclerosis, interstitial lung disease, GAVE with multiple cauterizations, and end stage kidney disease.  In past medical history, she listed “scleroderma renal crisis, “Started dialysis December 30, 2011,” and “Pneumonia. Admitted to er 6/24/12.”  She noted that the patient had had multiple upper endoscopies for gastrointestinal bleeding prior to this EGD.  Her physical examination listed “Lungs: Clear Auscultation. Clear percussion and Normal Symmetry and Expansion.”  She noted that she, not an anesthesiologist, was ordering sedation.

Sedation was to be administered by a registered nurse.  The gastroenterologist listed Airway as Class 2 and ASA Level (American Society of Anesthesiologists physical status classification system) as 3 (severe systemic disease).

On 6/25/2012 at 2:48 p.m. and ending at approximately 3:15 p.m., the gastroenterologist performed an upper endoscopy on the patient and took biopsies.  Nursing records indicate that sedation consisted of midazolam, 7 mg, administered over the 22 minutes; fentanyl, 175 mcg administered over the 22 minutes, and Cetacaine spray applied to the throat prior to the procedure.

The patient was transferred from the endoscopy procedure room to the recovery area under the care of a registered nurse.  The nurse noted that the patient was unresponsive to verbal and painful stimuli, with blood pressure 108/70, heart rate 86, and O2 saturation 89% on 2 liters delivered by nasal cannula.  A face mask was applied at 10 liters O2 and oxygen saturation went up to 97%.  When the gastroenterologist was notified, she ordered reversal medications: flumazenil 0.25 mg IVP over 15 seconds and Narcan 0.4 mg IVP at 3:40 p.m., and the patient was still unresponsive.  A second dose of flumazenil 0.25 mg IVP was given at 3:43 p.m., and the patient became responsive at 3:44 p.m.  Once the patient was responsive, the gastroenterologist performed the esophageal manometry procedure.  No time is entered in the medical record for this procedure although the gastroenterologist acknowledges that it was done and the results are recorded.

The gastroenterologist was later notified by nursing staff of concerns with the patient’s breath sounds, and the gastroenterologist noted stridor at 4:26 p.m.  She was notified at 5:19 p.m. that the patient’s oxygen saturation was 89% on 5 liters oxygen delivered by nasal cannula.  At 5:20 p.m., the gastroenterologist ordered a chest x-ray due to the inability to wean the patient off oxygen after the endoscopy.  A face mask was applied at 10 liters oxygen at 5:21 p.m., and oxygen saturation went up to 93%.  The chest x-ray indicated “a dense retrocardiac opacity and a left pleural effusion” and a “volume loss in the left lung with mild shift of the mediastinum towards the left.”

After the manometry procedure in the recovery room, the patient’s oxygen saturation was monitored, and when the oxygen saturation remained above 90% for 30 minutes on room air, the patient met endoscopy discharge criteria.  The patient was discharged home with instructions concerning any complications that might arise.

The gastroenterologist states that she arranged to admit the patient to the hospital, but the patient left against medical advice (AMA).  Neither notation of this nor a signed AMA release was found in the record.  Pathology results revealed gastritis and the manometry procedure revealed a condition consistent with esophageal scleroderma.

On 6/27/2012, the patient presented to the emergency department with shortness of breath and cough.  Chest x-ray showed new right lung patchy opacities, and the patient was cachectic.  He was admitted to the intensive care unit for treatment of pneumonia.  The admission diagnosis was “most likely persistent pneumonia, likely aspiration due to esophageal dysmotility.”  The patient failed to improve despite intensive hospital care.  Although the gastroenterologist had scheduled a PEG for 7/2/2012, it was decided that the patient would not go through with the procedure.  Instead, it was decided that the medical team would provide palliative care for the patient.

On 7/4/2012, the patient died with the cause of death listed as aspiration pneumonia due to esophageal dysmotility and end-stage scleroderma with severe malnutrition as a contributing factor.

The Board deemed the gastroenterologist’s conduct as falling below the standard of care for the following reasons:

1) The gastroenterologist failed to provide an accurate analysis of the patient’s suitability for the endoscopic and manometry procedures.

2) She classified the patient as an ASA Level 3, which denotes an individual with stable multiple system disease that limits daily activity without immediate danger of death.

3) At the time of the EGD and manometry done by the gastroenterologist, the patient had just been released from another hospital, where he had been treated for aspiration pneumonia and discharged on antibiotics and home oxygen.

4) By reason of the patient’s recent aspiration pneumonia and the necessity for home oxygen administration, his ongoing scleroderma renal crisis which necessitated hemodialysis, his persistent interstitial lung disease, and his frequent bleeding and cauterizations for GAVE, his condition was not stable, and elective procedures at this time were contraindicated.  The patient’s classification was clearly ASA level 4, which denotes an individual with severe, incapacitating disease, poorly controlled or end-stage, at risk for death due to organ failure.

5) The gastroenterologist failed to provide for an anesthesiology consultation, given the patient’s unstable and life-threatening condition, and instead elected to provide conscious sedation directed by the gastroenterologist and administered by a registered nurse.  The level of sedation administered to the patient during the upper endoscopy procedure was relatively large for an individual with so many co-morbid conditions, and an anesthesiologist or nurse anesthetist should have been in attendance.

6) Since both procedures were elective, the gastroenterologist failed to reschedule the procedures for a time when the patient was stable and able to tolerate conscious sedation directed by the gastroenterologist and administered by a nurse.

7) The patient had a very unstable post-procedure course in the recovery room.  He was unresponsive to verbal and painful stimuli and oxygen saturation was below 90%.  Reversal medications had to be administered before the patient became responsive.  When the patient became responsive, the gastroenterologist performed the esophageal manometry in the recovery room.  This procedure was unnecessary to determine the need for a PEG and further endangered the health of the patient.

8) The respondent approved sending the patient home with instructions after his oxygen saturation was above 93% for 30 minutes.  The patient was a very high-risk patient for elective procedures and had had a very unstable post-procedure course in the recovery room, including the development or exacerbation of pneumonia.  Under these circumstances, in conjunction with his numerous co-morbidities, it was unsafe to send the patient home.  There was no record found of the patient leaving the clinic AMA.

The Board issued a public reprimand against the gastroenterologist.  Stipulations included continuing medical education in the topics of pre-operative patient evaluation, informed consent, sedation, and medical record keeping.

State: California


Date: May 2017


Specialty: Gastroenterology, Hospitalist, Internal Medicine


Symptom: GI Symptoms (GERD, Abdominal Distention, Dysphagia), Cough, Shortness of Breath, Weight Loss


Diagnosis: Gastrointestinal Disease, Pneumonia, Pulmonary Disease


Medical Error: Unnecessary or excessive treatment or surgery, Failure of communication with other providers, Lack of proper documentation


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 5


Link to Original Case File: Download PDF



California – General Surgery – Abdominal Pain And Tachycardia Following A Laparoscopic-Assisted Ileocolectomy With A Stapled Anastomosis For Tumor Removal



On the morning of 6/17/2013, a 79-year-old male underwent a scheduled colonoscopy by his gastroenterologist due to symptoms of chronic abdominal pain, weight loss, and anemia.  The colonoscopy revealed a tumor in the ascending colon. A general surgeon was called in for a surgery consultation. The general surgeon met with the patient and his family and obtained an informed consent from the patient to perform surgery later that same day.  The general surgeon failed to document this consultation with a written or dictated note in the patient’s medical record. Later that same day, on the evening of 6/17/2013, the general surgeon performed a laparoscopic-assisted ileocolectomy with a stapled anastomosis on the patient and removed the tumor.

During the first 2 days following the operation, the patient began to show signs of complications.  He had mild leukocytosis and bandemia as well as no obvious gastrointestinal function. Late in the day of 6/19/2013 and into 6/20/2013, the patient began having increased abdominal pain and increased abdominal distention.  On 6/20/2013, the general surgeon ordered an increase in the patient’s IV fluids. The general surgeon reported that she made a focused exam of the patient, but she failed to note any details describing the quality of the patient’s abdominal tenderness in the medical record.  Later that same day, the patient experienced greater abdominal pain and became tachycardic with an elevated heart rate. The patient’s family became increasingly concerned and repeatedly asked for something to be done to help the patient. At 12:40 a.m. on 6/21/2013, the nurse called the general surgeon.  The general surgeon’s only intervention at that time was to give verbal orders to the nurse to increase the patient’s pain medication, place a catheter, and order partial blood work. The general surgeon did not come to the hospital and did not examine the patient. Yet, when the general surgeon was interviewed by the Medical Board, she stated that at this point “it was clear that something wasn’t as it should have been.”

The standard of care requires that at this point, if not sooner, a work up for Systemic Inflammatory Response System (SIRS) or Sepsis should have been ordered, including possibly starting IV antibiotics, ordering specific lab tests and diagnostic imaging, and doing a focused physical exam.

Over the next 4 to 5 hours on 6/21/2013, the patient complained of severe abdominal pain, had increased tachycardia, and a worsening appearance.  At 5:03 a.m., the nurse again called the general surgeon. The general surgeon again gave verbal orders only for fluids, increased pain medications, and an x-ray.  At 6:15 a.m., it was first documented that the patient had a fever of 100.2 F, which increased to 103.1 F by 7:55 a.m.  The patient had also become hypotensive with low blood pressure.  At this point, it should have been clear to the general surgeon that the patient was in septic shock.

At 8 a.m., the general surgeon, who was still not in the hospital, gave the nurse the order over the phone to transfer the patient to the critical care unit.  The first documentation that the general surgeon was present in the hospital was a nurse’s note at 8:30 a.m. Upon examination, the general surgeon suspected the patient was suffering from peritonitis in addition to septic shock.  The patient was taken to the critical care unit between 8:45 a.m. and 9 a.m. and emergently to the operating room at around 9:30 a.m.

The general surgeon performed an exploratory laparotomy on the patient, where feculent fluid was found coming from a small disruption of the ileocolic anastomosis.  The fluid was suctioned, the abdomen irrigated, the ileocolic anastomosis resected, and another anastomosis was created. The patient remained hemodynamically unstable throughout the procedure and was transferred to the critical care unit still intubated on multiple pressors for blood pressure support.  The patient’s primary care was transferred to the critical care unit doctors. The patient likely aspirated during intubation. For the next several days, the patient remained in septic shock and dependent on a ventilator. He suffered progressive multi-organ failure, which led to his death on 6/28/2013.

The Medical Board of California judged that the general surgeon’s conduct departed from the standard of care because she failed to conduct an adequate work-up and significantly delayed coming to see the patient, who was exhibiting worsening abdominal pain and clinical signs and symptoms, which met SIRS criteria, and then progressed to septic shock.  The general surgeon also performed a primary ileocolic anastomosis without a fecal diversion in a hemodynamically unstable patient in septic shock, who had feculent fluid peritonitis.

The Medical Board of California issued a public reprimand and ordered the general surgeon to complete a medical record-keeping course and education course for at least 40 hours.

State: California


Date: November 2016


Specialty: General Surgery


Symptom: Abdominal Pain, Fever, GI Symptoms (GERD, Abdominal Distention, Dysphagia), Weight Loss


Diagnosis: Post-operative/Operative Complication, Sepsis


Medical Error: Failure to order appropriate diagnostic test, Delay in diagnosis, Failure to examine or evaluate patient properly, Improper treatment, Lack of proper documentation


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



California – Pediatrics – Premature Baby Tests Positive For Methamphetamine And Fails To Thrive



On 9/23/2011, the patient, a baby boy, was born prematurely at a hospital. He was estimated to be approximately 32 weeks gestation at birth, weighing 2 pounds 15 ounces.  Both he and his mother tested positive for methamphetamine.

The patient remained in the neonatal intensive care unit (NICU) for five weeks and was discharged on 10/30/2011.  The patient’s weight at discharge was 5 pounds, 10 ounces. The discharge instructions to his mother directed her to follow up with several resources and appointments for the patient, including the following:

1) Central Valley Regional Center, Children’s High-Risk Infant Follow Up program,

2) a local ophthalmologist,

3) the Public Health Nurse, and

4) a pediatrician.

On 11/2/2011, the patient’s mother brought him for his appointment with the pediatrician.  The records of this appointment reflected a normal physical examination. The pediatrician recorded that the patient was 6 pounds, 9 ounces; his height was 71.5 inches; and no head circumference was recorded.

The past medical history was stated as “premature.” The assessment was “medical exam routine.” The follow-up plan was for the patient to return in three months, 2/7/2012, for a California Department of Public Health Physical (CDHP) examination.

The pediatrician’s notes did not reference the NICU discharge summary, and there was only a partial copy of the discharge summary in the chart.

Although the pediatrician did not begin a growth chart for the patient at the 11/2/2011 visit, the patient’s weight and age place him approximately at the 30th percentile for growth at this visit.  This notation is presumably a typographical error in the record.

On 2/7/2012, the patient’s mother brought him back to the pediatrician for the next regularly scheduled appointment. At this appointment, the patient’s weight was 9 pounds 3 ounces, his height was 20.5 inches, and his head circumference was 38 centimeters.

The pediatrician did not chart a physical examination.  The pediatrician listed his assessment at this appointment as “Routine Infant,” and his plan included anticipatory guidance, immunizations, and follow-up in two months.  The pediatrician did not begin a growth chart for the patient at the 2/7/2012 visit. If the pediatrician had been charting the patient’s growth, the chart would have shown that his recorded weight and age place the patient below the first percentile for growth at the 2/7/2012 visit.  The patient’s mother did not bring him back for his next appointment, which should have been in March 2012.

Instead, she returned on 6/28/2012 with a presenting complaint that the patient had congestion and dry skin.  At this appointment, the pediatrician recorded that the patient weighed 10 pounds and 13 ounces, had a height of 22 inches, and had a temperature of 99.7 degrees Fahrenheit.

If a growth chart had been maintained, it would have shown that the patient had fallen even further below the first percentile for growth at this visit. Upon examination, the pediatrician found “cracking of the skin around the ear,” “Nose; congested for 2 days,” and “Chest and Lungs; Cough and congestion X 2 days, tight cough. Exp. Phase of resp is increased with respect to the inspiratory phase of respiration, Rx with nebulized Xoponex.”

A respiratory rate or oxygen saturation was not documented. Under assessment, the pediatrician found the patient had impetigo, asthma, acute bronchitis, iron deficiency anemia, and seborrheic dermatitis.

He prescribed an antibiotic ointment twice a day, a Hydrocortisone 1% ointment, a ten-day course of amoxicillin, an iron supplement, and a nebulizer. The pediatrician directed the patient’s mother to return if he had no improvement, and otherwise to return in two months for follow-up of his asthma.

On 8/9/2012, the patient’s mother called 911 to report that the patient was not breathing. An ambulance arrived and transported the patient to the hospital where he was pronounced dead. Upon examination, the patient’s body had several areas of skin breakdown, and he was found to be severely malnourished. At the time of his death, the patient’s weight was 7 pounds 6 ounces.

The Board judged the pediatrician’s conduct to have fallen below the minimum level of competence given failure to have the infant return in one week after his first pediatrician visit, failure to elucidate the extent of his prematurity in the past medical history, failure to reference the full discharge summary from the NICU, failure to make a growth chart for the patient, and failure to address the patient’s failure to thrive.

The Board issued a public reprimand with stipulations to complete a medical record keeping course and enroll in a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California – San Deigo School of Medicine.

State: California


Date: April 2016


Specialty: Pediatrics


Symptom: Weight Loss, Cough, Dermatological Abnormality


Diagnosis: N/A


Medical Error: Failure to properly monitor patient, Diagnostic error, Improper treatment, Lack of proper documentation


Significant Outcome: Death


Case Rating: 2


Link to Original Case File: Download PDF



California – Internal Medicine – Lack Of Diagnosis For Flank Pain, Fever, Abdominal Distention, And Weight Loss



An internist first saw a patient on 8/27/2007. The patient was a 55-year-old male who had a history of variably-controlled hypertension, dyslipidemia, and prior coronary bypass surgery in 2009.  On 11/30/2009, the internist saw the patient for a follow-up visit.  The internist noted that his weight at the time was 243 lbs.  He had been placed on a number of medications for coronary artery disease.  Pre-operative and post-operative x-rays did not show any significant findings.  On 1/27/2010, the internist had changed to an electronic medical records system.  The internist saw the patient and noted the following under Review of Systems:

“General/Constitutional: General able to do usual activities, good exercise tolerance, good general state of health, no fatigue, no fever, no weakness, no weight loss or gain.  Appetite yes. no Anxiety.  no Bleeding problems.  no Appetite reduced.  no Body aches.  no Bowel movement, no Breastfeeding.  no Chills, no Chronic fever.  no Cold limbs (feet, hands).  no Coldness (feel cold when others are comfortable).  no Concerns.  no Elimination, no Energy level.  no Fatigue, no Feeling weak, no Fever, no Formula feeding.  no Fussy, no Hemoptysis, no Ill contacts.  no Insomnia.  no Loss of appetite, no Loss of height.  no Lymph nodes, swollen glands, no Malaise.  no Night Sweats, no Nutrition. n o Opioid management, no Pain quality.  no Personal assessment of current health.  See HPI for details.  no Skin rash, no Sleep.  no Sweats.  no Weakness, no Weight change.  no Weight gain.  no Weight loss.”

The internist documented on the 1/27/2010 note under the patient’s Review of Systems that he had “no formula feeding”, “no breastfeeding’, and “no fussy.”  The internist also noted the patient had “no bowel movement,” “No nutrition,” “No elimination,” “no Opioid management,” and “no Pain quality.”   The internist did not document anything in the progress note to clarify these entries.  The internist noted the following under the 1/27/2010 Objective portion of the note under General Examination:

“General Examination: GENERAL APPEARANCE: alert, Build: average, in no acute distress, pleasant.  HEENT: unremarkable.  NECK/THYROID: no lymphadenopathy, supple.  CARDIOVASCULAR: normal SlS2, regular rate and rhythm, normal S1S2, regular rate and rhythm, no murmurs.  RESPIRATORY: clear tauscultation (sic) bilaterally, no wheezes, rhonci, rlaes (sic).  GASTROINTESTINAL: no hepatosplenomegaly, no masses palpated.  NEUROLOGIC EXAM: non-focal exam.  SKIN: normal, no rash.  EXTREMITIES: no clubbing, no edema, BREAST: normal.”

The internist did not clarify why he had to perform a breast exam on the patient.  The internist did not document any findings under the progress note regarding history of present illness and family history.  Most of his subsequent progress notes were copy and pasted into the next one, propagating the above physical exam and review of systems.

The progress note on 4/5/2010 was a verbatim copy of the prior note.

On 10/5/2010, vital signs showed that the patient had gained weight, contrary to the entry under the Review of Systems which showed no weight gain and no change in weight.

On 12/9/2010, a rectal and prostate examination was performed.  The internist did not document the reason why the rectal and prostate examination was performed.  The internist also added benign hyperplasia of the prostate under the assessment portion of the progress note.  He also added the diagnosis of esophageal reflux.  The internist did not explain these diagnoses or provide evidence to support these diagnoses.

On 12/20/2010, the patient presented to the clinic with a chief complaint of “Rt. side pain.”  The internist noted a distended abdomen in the physical examination but noted no rigidity, no rebound, bowel sounds positive in the physical examination.  The internist did not document any differential diagnosis for the abdominal distention.

On 12/27/2010, the internist saw the patient for an office visit.  The internist documented a diagnosis of “Alcoholic cirrhosis of liver” without any documentation of any findings or his reasoning to support this diagnosis.  The internist did not document the results of the ultrasound tests.

On 1/12/2011, the internist documented a continuing diagnosis for alcoholic cirrhosis of the liver without any reference to how this diagnosis was obtained.  The internist also diagnosed hip pain without any supporting documentation in any of the subjective or objective portion of the progress note.  The internist documented “no pain’ under Review of Systems.

On 1/31/2011, the internist saw the patient for an office visit.  The patient complained of hip pain.  The internist documented “no pain” in the review of systems.  The internist documented ascites as a diagnosis but did not document his findings to support the diagnosis.  The internist did not document under the Objective General Examination portion of the progress note that the patient had lost 22 lbs and that he had a temperature of 100.5 degrees.

On 2/7/2011, the patient presented with flank pain 10/10 one month duration, fever, and weight loss.  On the same date, the patient was subsequently seen at the emergency department, complaining of right flank pain for 3 weeks.  The ER physician spoke with the internist who indicated that he would see the patient the next day and arrange for an “urgent MRI of the back to check for radicular pain and also for any neoplastic process.”  The final diagnosis at the emergency department visit was “Flank and back pain, unknown cause.”

On 2/8/2011, the internist documented the chief complaint as “fu from er – need to complete FMLA paperwork and Insurance paperwork (pays him when he is out of work).”  The internist did not document the reason for the emergency room visit or the significance of the findings and seriousness of the patient’s condition at the emergency department visit.  The internist did not document any weight loss, tachycardia, or new constitutional symptoms.

The patient’s weight at this visit was 183 pounds (down from 192 pounds just eight days prior), pulse was 107, and temperature was 99.3 degrees Fahrenheit.  The internist did not document any constitutional symptoms that the patient may have been manifesting.  The internist did not mention or address the weight loss and fever.  As reported by the Board, the internist documented back pain, without addressing the finding of abdominal distention. T he internist did not take an adequate history, failed to assess the seriousness of the situation, and further failed to request immediate testing and follow-up.  The internist failed to promptly order the MRI of the lumbar spine, assure its timely completion, and schedule prompt follow-up with the patient.

On 2/17/2011, the patient was seen by a gastroenterologist. The internist requested the consultation on 1/31/2011.  The gastroenterologist documented right flank pain, sharp and severe, 7/10 on a pain scale, fever, chills, malaise, poor appetite, and weight loss of 24 pounds.

On 2/27/2011, the patient presented to the emergency department again.  The patient presented with chest pain, and documented flank pain of two month’s duration, fever of five to six weeks duration, and a “55 pound weight loss since January.”

The patient was transferred to another hospital, and he underwent an uncomplicated ultrasound-guided left hemodialysis catheter placement.  He also underwent an IR guided L1 paraspinal mass biopsy with aspiration on 3/1/2011.  Hematology/Oncology was consulted given the possibility for multiple myeloma and lymphoma.

On 3/2/2011, the patient was intubated for respiratory distress and had been on pressors.  A pathology report showed innumerable coccidioidomycosis species with innumerable spherules ladened with endospores. The patient subsequently deteriorated and died.

The Board issued a public reprimand with stipulation for the internist to complete a medical record keeping course.

State: California


Date: November 2015


Specialty: Internal Medicine, Family Medicine, Hospitalist, Infectious Disease


Symptom: Abdominal Pain, Fever, Weight Loss


Diagnosis: Infectious Disease


Medical Error: Failure to order appropriate diagnostic test, Delay in proper treatment, Failure to examine or evaluate patient properly, Failure to follow up, Lack of proper documentation


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Obstetrics – Pregnant Patient With TSH Of 0.10 MIU/L



On 1/9/2013, a 25-year-old female patient began her first pregnancy care at a medical center where she was examined by a physician.  The patient was in her first trimester of pregnancy.  The patient weighed 154 pounds.  The physician ordered laboratory analysis of the patient’s thyroid stimulating hormone (TSH) blood level.

On 2/1/2013, a sample of the patient’s blood was collected for TSH analysis.

On 2/5/2013, the TSH level result was reported low at 0.10 MIU/L with a first trimester reference range of 0.26-2.66 MIU/L.

On 2/7/2013, the patient returned to the medical center for obstetric follow-up and complained that she could not hold down food.  The patient weighed 150 pounds.  An obstetrician evaluated the patient.

The medical records document that on 1/22/2013 the patient had been prescribed Zofran 8 mg, with instructions to take one tablet every eight hours for fifteen days.  Zofran is the brand name for ondansetron, an anti-emetic used during pregnancy for treatment of morning sickness, nausea, and vomiting.

On 2/7/2013, the medical records document that the patient would be traveling for three months.

The obstetrician prescribed Phenergan suppositories to the patient.  Phenergan is the brand name for promethazine, an antihistamine with antiemetic properties used during pregnancy to treat morning sickness, nausea, and vomiting.

On 2/7/2013, the medical centers records documented the patient’s low TSH test result from 2/1/2013.  The obstetrician failed to recognize the significance of the patient’s complaints and TSH test results.  The obstetrician did not order additional tests to evaluate the patient’s low TSH at any time during his care of the patient.  The obstetrician did not inform the patient of her low TSH result at any time during his care of the patient.  The obstetrician instructed the patient to return as needed.  The obstetrician did not plan close follow-up of the patient’s complaints of weight loss.  The obstetrician did not refer the patient to a specialist for evaluation of her low TSH.

Following her 2/7/2013 visit with the obstetrician, the patient was diagnosed with and began treatment for hyperthyroidism while visiting Iran.

The Board judged the obstetrician’s conduct to be below the minimum standard of competence given his failure to recognize the significance of the patient’s symptoms and test results, advise the patient of her low TSH, order laboratory analysis of T3 and T4 blood levels, plan close monitoring of the patient’s symptoms and thyroid hormone levels to prevent a delay in diagnosis of hyperthyroidism, diagnose the patient’s hyperthyroidism, or refer the patient to an endocrinologist for evaluation.

The Board ordered that the obstetrician pay a fine of $5,000 against his license and pay reimbursement costs for the case for a minimum of $3,076.77 and not to exceed $5,076.77.  The Board also ordered that the obstetrician complete a medical records course in “Quality Medical Record Keeping for Health Care Professionals” and complete five hours of continuing medical education in “Risk Management.”  The Board ordered that the obstetrician complete one hour lecture/seminar on prenatal screening, including screening for hyperthyroidism.

State: Florida


Date: February 2015


Specialty: Obstetrics, Endocrinology


Symptom: Weight Loss


Diagnosis: Endocrine Disease


Medical Error: Diagnostic error, Referral failure to hospital or specialist, Failure of communication with patient or patient relations, Failure to follow up, Failure to properly monitor patient


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Pediatrics – Antiviral Drugs And Antibiotic Medications For Teenager Diagnosed With HHV-6



In October 2009, a female teenager with a history of premature birth at 34 weeks was hospitalized and diagnosed with Systemic Lupus Erythematosus.  The patient developed multiple organ distress preceded by a one-month history of intermittent low-grade fever, nausea, and weight loss.  A pediatrician, who had been treating the patient since birth, advised the patient’s mother that the patient exhibited some signs of cognitive-motor dysfunction that were on the autistic spectrum.

In 2005 or 2006, the pediatrician stated that the patient had activation of human herpes virus 6 (HHV-6) for which the pediatrician prescribed antiviral medications.  The records maintained by the pediatrician for the patient did not indicate the reasons for the antiviral medications or were too illegible to read or decipher.  Also, the pediatrician’s records did not document the reasons for his HHV-6 diagnosis and testing.  The pediatrician recommended that the patient be treated with Imunovir from a Canadian pharmacy, which was being used on adults with HIV/AIDS.  The pediatrician did not document the reasons for wanting to use the non-approved medications and did not advise the patient or her parents of the risks associated with its use or did not document that he did so.  Each Canadian prescription of Imunovir cost around $270 and contained 100 pills.  The medication was discontinued when the patient’s parents could no longer afford to pay for it.  The pediatrician prescribed antiviral drugs, such as Valtrex, Acyclovir, and Famciclovir over a long time as well as regularly prescribed antibiotic medications for multiple acute infections.  The pediatrician told the patient’s parents that HHV-6 had been correlated with multiple sclerosis, heart disease, and leukemia and continued treatment could reduce the incidence of these conditions.

In August 2009, the patient worked as a summer camp volunteer and was in direct sunlight all day, every day.  The pediatrician did not advise the patient or her parents that the patient should limit exposure to direct sunlight or did not document that he did so (lupus and acyclovir increase the skin’s sensitivity to the sun).  During September 2009, the pediatrician treated the patient with a variety of antibiotic medications.  The patient began losing weight.  The pediatrician told the patient that she was not eating properly.

The pediatrician treated the patient for approximately 15 years, and when her condition worsened in September 2009, the pediatrician did not refer the patient to another specialist or suggest that the parents take their daughter to another physician for evaluation.

The Medical Board of California judged that the pediatrician’s actions represented a departure from the standard of care because he prescribed antiviral and antifungal medications in a preventive manner when the patient did not exhibit symptoms for such medications or without adequate documentation, engaged in or provided unapproved treatment without advising the patient or the patient’s parents or obtaining an informed consent or documenting having obtained informed consent, failed to diagnose or treat the patient in accordance with commonly accepted peer and professional guidelines for children, failed to formulate and provide a clear diagnosis and treatment plan for the patient or not documenting such plans, not referring the patient to another specialist in a timely manner, failed to advise the patient to avoid direct sunlight or documenting such advice, and failed to document the reasons for the various medications he prescribed for the patient.

The Medical Board of California ordered that the pediatrician complete a medical record-keeping course, clinical education program, and education course (at least 40 hours per year for three years) equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California


Date: January 2014


Specialty: Pediatrics


Symptom: Weight Loss, Fever, Nausea Or Vomiting


Diagnosis: Autoimmune Disease


Medical Error: Referral failure to hospital or specialist, Diagnostic error, Failure of communication with patient or patient relations, Improper medication management, Unnecessary or excessive treatment or surgery, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Internal Medicine – Normal Saline And Low Salt Diet For Hyponatremic Patient Who Recently Lost 30 Pounds



A 45-year-old African American female patient began treatment with an internist.  She suffered from depression, hypertension, and seizure disorder and admitted to abusing cocaine.  She was seen at the internist’s downtown office regularly, on average about every 3 months, from 3/30/2005 to 1/5/2009.

A lumbar spine x-ray was done on 2/13/2006.  Significant findings included a one centimeter focal density in the L2 vertebral body towards the pedicle.  A neurology consultation by another physician was documented.

The internist employed multiple nurse practitioners (NPs) and physician assistants (PAs) to help with evaluating patients and performing hospital rounds.  The office progress notes were invariably a preprinted form documenting individual visits. However, the written descriptions were scant and largely illegible.  Most signatures from the office progress notes were different from the internist’s signature, indicating that the internist’s assistant(s) saw the patients. Almost none of the progress notes showed documentation of physical examinations; the preprinted physical examination sections were usually left blank.

On 9/5/2006, the patient visited the internist and reported a 30-pound weight loss.  No physical examination was documented for this visit. The assessment included seizure disorder, hypertension, psychiatric disorder, osteoarthritis, and weight loss; however, there was no actual statement describing the current status of each condition.  Furthermore, no differential diagnosis was made as to the cause of her significant weight loss.

During the next visit on 11/6/2006, no follow-up note was made regarding the patient’s weight loss.  Around mid 2006, multiple tumor markings and CT scans of the chest and abdomen were ordered. There was no entry in the medical records indicating the result of these tests.  In addition, there were no comments on this reflected in any of the following progress notes.

The patient was admitted to a medical center from 9/7/2006-9/9/2006.  The initial history and physical examination documented the admitting diagnosis of hypertension, fatigue, shortness of breath, and hyponatremia.

Nonetheless, the internist ordered a low salt diet and intravenous 0.5 normal saline solution upon the patient’s admission; these orders continued unchanged to the end of her hospitalization.  In addition, no follow up sodium levels were ordered during this hospitalization. The dictated history and physical examination done in the evening of 9/8/2006 indicated that the patient’s blood pressure was 111/65, which was normal.  The plan was to start intravenous normal saline, although the main diagnosis was hypertension. A chest x-ray done on 9/8/2006 was reported unremarkable by the radiologist.

An office progress note dated 4/17/2008 documented that the patient was to be directly admitted to the hospital for diarrhea and weakness.  However, there was no follow up record on whether that occurred or what happened there if it did.

The internist’s office progress notes lacked relevant history and physical findings as evidenced by the fact that the physical examination portion of the preprinted progress notes were left blank.  The internist did not document fully or adequately to justify the patient’s diagnosis or treatment plan. The patient’s hospital admission documented a diagnosis and did not match pertinent treatment.  The notes that existed appeared to be random and were disorganized.

The internist committed an extreme departure from the standard of care by failing repeatedly to complete his own progress note/form regarding history and physical examination findings.  His hospital record keeping was not clear in terms of diagnoses, plan of care, and justification for admissions. The internist committed an extreme departure from the standard of care in failing to perform appropriate, if not full, evaluation and treatment on multiple occasions for the patient as set forth.  There were no specific findings leading to an actual diagnosis. Appropriate tests were also frequently not ordered for the purported diagnosis. Furthermore, apparent erroneous treatments were ordered specifically, ordering intravenous half normal saline fluid and low salt diet for the patient, who had hyponatremia.  The internist further committed an extreme departure from the standard of care in that he exercised insufficient judgement before admitting the patient to a hospital as an inpatient. Physicians are required to establish justifiable reason for admitting patients as an inpatient in any hospital, and the internist did not do that.

The Medical Board of California placed the internist on probation for five years and ordered him to complete a medical record keeping course, a professionalism course, a clinical training program, and have a practice monitor for the duration of his probation.

State: California


Date: December 2013


Specialty: Internal Medicine


Symptom: Seizure, Diarrhea, Shortness of Breath, Weakness/Fatigue, Weight Loss


Diagnosis: N/A


Medical Error: Lack of proper documentation, Failure to examine or evaluate patient properly, Failure to properly monitor patient, Improper supervision, Improper treatment


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Family Medicine – Lyme Disease Patient Treated With Over 50 Medications And Herbal Remedies



On 3/25/2010, a 54-year-old male patient was seen at a family practitioner’s office for evaluation of Lyme disease.  The patient did not recall having a tick bite or developing any rash or lesions. The patient reported numerous complaints including fatigue, flu-like symptoms, loss of appetite, hair loss, sore throat, sore glands, night sweats, chills, chest pain tightness, musculoskeletal pain and swelling, anxiety attacks, decreased concentration, headaches, memory problems, mood swings, nightmares, panic attacks, poor balance and difficulty walking, seizures, difficulty sleeping, tremors, and weakness of limbs, abdominal pain, constipation, nausea, vomiting, and weight loss.  The patient reported that he had never been diagnosed with Lyme disease.

Laboratory tests conducted in April 2010 were negative for Lyme disease. The family practitioner’s notes, dated 5/11/2010, also stated that laboratory tests were negative for Lyme disease, and the family practitioner’s assessment was “myalgias with hyperesthes.”  Despite the negative laboratory results, the family practitioner noted that “Bartonella/Lyme is still a possibility,” and the patient was started on the “Cowden protocol,” a homeopathic protocol for treating Lyme disease, and also started on “BSP 201,” a supplement.

On 6/10/2010, the family practitioner prescribed doxycycline.  On 9/13/2010, the patient was examined by a physician assistant, who noted that the patient was doing poorly overall.  The physician assistant’s assessment was “probably lyme.” No vital signs were recorded.

The patient continued to complain of worsening symptoms and saw the family practitioner and/or the physician assistant on approximately a bi-monthly basis through at least March 2012.  The patient’s vital signs were not recorded during these visits.

The family practitioner’s notes dated 11/2/2010 stated that the patient had “remarkable pain, fatigue, weakness, malaise, and significant reactivity.  He is unable to control the pain with the current regimen.” The family practitioner assessment was “Lyme with severe full body symptoms, quite ill.” The family practitioner’s plan included starting “ketamine IV,” “obtain a KPU and copper,” “Continue the current regimen with Dr. R,” and “Consider remediating the house for mold.”

The family practitioner’s notes dated 2/2/2011 stated that the patient had complaints of “profound fatigue and weakness” and that “Overall, the patient continues to do poorly.”  The family practitioner also noted that the patient was “still addressing mold and would like to begin a more aggressive treatment for Lyme.” The family practitioner’s assessment was “Lyme,” “Mold,” and “Neurologic decline.”  The family practitioner’s treatment plan included: “consider ketamine,” “consider a port,” “recommend IV [g]arlic.”

Progress notes from 2/28/2011 indicated that the patient was seen by the physician assistant, who noted that “patient continues to do poorly.  Profound fatigue and weakness.” IV garlic was started. In addition, oral Septra was started, and the patient was continued on Sporanox and nystatin.  He was also continued on Lymphomyosot and Itires, both homeopathic remedies.

A list of the patient’s medications from February 2011 indicated that he was being treated with over 50 medications, supplements, and herbal/homeopathic remedies.  The family practitioner’s notes dated 4/14/2011 stated that the patient had “severe tendinosis and full body pain.” The family practitioner noted that Dr. R’s priorities were “Borrelia and heavy metals.”  The patient reported feeling much worse for several days after the IV garlic treatment. The patient reported having to increase his pain medications, having severe nausea and severe weakness, and needing to walk with a cane.  The family practitioner’s treatment plan was to “ramp up Rocephin,” “start Actigall,” “decrease [g]arlic,” and “use ketamine intranasal every few hours.”

On 5/5/2011, the patient was admitted to the hospital with complaints of fever, chills, and abdominal pain.  The patient reported having received IV garlic and IV DMSO (Dimethyl sulfoxide) infusions through a Mediport.  The patient was diagnosed as having Klebsiella oxytoca bacteremia and Gallbladder dyskinesia. The patient’s Mediport was removed, and he was discharged on 5/9/2011 with the advisement not to take any IV materials and substances that were not FDA approved and manufactured under strict FDA regulations to ensure standards of safety.

Following his discharge from the hospital, the patient continued to receive treatment under the family practitioner’s care including treatment with IV Levaquin, IM Invanz, Takuna, Transfer Factor, increased dosage of nystatin, Yeast Ease, Olive Leaf Extract Secure, Enhansa, Aloe 225, Magnesium Malate, vitamin C, GI revive, Aloe vera juice, Chamomile Tea, DGL, Cromolyn sodium, Reglan, Cryptolepis, and Malarone.  The family practitioner also noted that “removing metals from mouth” should be considered.

The patient’s medication list dated 11/28/2011 identified over 15 prescribed medications, 4 herbal/homeopathic remedies, and 29 supplements.  There was no evidence that the family practitioner obtained informed consent to treat the patient with IV garlic, IV glutathione, IV DMSO, or IV Ketamine.

The family practitioner’s overall conduct, acts and omissions with regard to the patient constitutes unprofessional conduct through gross negligence and repeated acts of negligence and incompetence.  More specifically, the family practitioner was guilty of unprofessional conduct with regards to the patient as followed: he continued to prescribe multiple courses of antibiotics for over a year, even though there were no signs of improvement; the family practitioner prescribed IV ketamine without medical indication; he subjected the patient to unnecessary therapeutic regime, including IV garlic, which resulted in serious harm; he failed to obtain informed consent regarding treatment with IV garlic, IV glutathione, IV DMSO, or IV ketamine; he failed to review his treatment plan with the patient, including failing to repeat laboratory tests to confirm whether the patient had Lyme Disease; and failure to routinely assess and document the patient’s vital signs.

The Medical Board of California ordered that the family practitioner be publicly reprimanded and attend 65 hours of an education course.

State: California


Date: November 2013


Specialty: Family Medicine, Internal Medicine


Symptom: Weakness/Fatigue, Constipation, Fever, Headache, Nausea Or Vomiting, Pain, Abdominal Pain, Chest Pain, Psychiatric Symptoms, Seizure, Swelling, Weight Loss


Diagnosis: Infectious Disease, Acute Abdomen


Medical Error: Improper medication management, Failure to order appropriate diagnostic test, Failure of communication with patient or patient relations, Failure to properly monitor patient, Unnecessary or excessive treatment or surgery


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Family Medicine – Nasal Sprays, Prednisone, And Antibiotics For 5-Month Persistent And Productive Cough



On 7/24/2006, a 59-year-old female patient came under a family practitioner’s care.  At her initial examination, the patient complained of wheezing in her chest and stated that the symptoms had been going on for the past month.  She reported that her nose and sinuses had been congested for a similar period of time and her ears were congested. The family practitioner did not review prior medical records.  Family history was stated to be negative for asthma or chronic lung disease. The patient was stated to have no allergies. Vital signs were within normal range, and findings on physical examination were reported to be normal.  Tympanic membranes were retracted. Her nasal mucosa was pale and edematous. Her lungs were described as clear, without wheezing or rales. The family practitioner’s assessment was allergic rhinitis. He prescribed a cortisone nasal spray to be used for 5 days with a 12-hour nasal decongestant and thereafter, to be used alone for 30 days.

The patient returned on 9/5/2006, complaining of a cough in addition to the wheezing she had reported at her July visit.  Using a software template for medical charts, the family practitioner replicated his prior note, including the same previous syntactic and typographical errors.  An additional history of tobacco use was obtained on this visit. Vital signs were normal and physical examination was reported to be unchanged. No additional diagnostic tests were performed or ordered, nor was there any documentation that possible tests or x-rays were considered by the family practitioner or discussed with the patient.  Extrinsic asthma with exacerbation was added to the family practitioner’s diagnoses for the patient, albeit the family practitioner did not follow the formal diagnostic protocol for asthma. The family practitioner did not stratify the patient’s asthma by spirometry and type and time of symptoms. She was given prescriptions for an albuterol inhaler, and a 5 day supply of prednisone and Zithromax were added to orders for a repeat course of Flonase and Afrin.

In a note written on 9/14/2006, the patient reported that she felt much improvement after the second course of treatment, however, on 10/6/2006, the patient telephoned to report that her symptoms had returned.  The family practitioner ordered a second course of prednisone, a 10-day course of Biaxin, 500 mg BID, and a repeat course of Zithromax. The rationale for the repeat courses of antibiotic treatment with Biaxin and Zithromax was not documented.  On 10/25/2006, the patient telephoned again to report that she was still wheezing and coughing. The patient stated that she was using her albuterol inhaler on a daily basis. The note stated that the patient desired additional antibiotics before she would come in and, according to the family practitioner’s chart, he agreed to prescribe another course of Zithromax.  He either did not inform the patient of the risks associated with another course of antibiotics, including ineffectiveness of the treatment or possible development of bacterial resistance, or he did not document the discussion. Although the family practitioner later stated that he would have considered a chest x-ray by this point in the patient’s course of treatment, there was no documentation of that, and moreover, there was no documentation of the patient’s informed refusal of an x-ray.

On 11/6/2006, the patient returned.  According to the family practitioner’s chart, she reported that illness had now lasted 4 months, that she had a cough productive of green sputum, and that the five courses of antibiotics she had been prescribed were not helpful.  As a result of an error in record keeping, the family practitioner’s chart notes for this examination was incomplete and did not document what occurred in this visit. No additional tests or x-ray examinations were ordered on this occasion.

On 12/18/2006, the patient returned to the family practitioner.  She stated that she had a cough that was productive of yellow sputum, which was worse at night, and that she had to sit up to catch her breath.  As on other visits, medical information from previous visits was copied into the chart note for this visit. Diffuse wheezing was noted. Inspiratory to expiratory ratio was noted to be prolonged.  The family practitioner gave the patient a prescription for another course of prednisone and a prescription for antibiotics, which was to be used only if she failed to improve after several days of prednisone.  She was prescribed another albuterol inhaler and instructed on the value of the Flunisolide nasal spray. The family practitioner continued his prior diagnosis of allergic rhinitis and asthma.

On 12/27/2006, the family practitioner re-examined the patient.  Although the patient had been noted to have gained weight on the two previous examinations, she now had lost 11 pounds in 9 days; however, the family practitioner’s records did not comment on the possible significance of that change.  The patient continued to complain of a cough, which was productive of green sputum. Spirometry was performed for the first time on that examination and the results were reported as “mild obstructive pattern without significant reversibility.”  The family practitioner continued his prior diagnoses and advised the patient to continue her use of nasal spray and the inhaler. The patient was told to return to the clinic in 3 months.

The patient continued to suffer from a persistent cough.  She reported to an acquaintance that she had coughed up blood on several occasions.  The acquaintance urged her to get a chest x-ray, which she did on 3/6/2007. The report of that examination including a detailed history of a cough for years, with gradual progression.  On physical examination, a diffuse wheezing was noted. A chest x-ray showed a possible mass in the right infrahilar region. A CT scan was recommended.

On 4/11/2007, the patient returned to the family practitioner’s office at which time he noted the results of the chest x-rays as a “right infrahilar density typical of mass lesion.”  The family practitioner made the diagnosis of possible lung cancer. He referred the patient to a pulmonary consultant for a CT scan.

On 4/16/2007, a chest CT was performed, and a 6 cm mass was discovered in the right hilum.  Hepatic lesions were also noted. The diagnosis was probable metastatic bronchogenic carcinoma.  The patient’s metastatic lung cancer, which the family practitioner failed to test for or consider during his care and treatment of the patient over 5 months in 2006, ultimately resulted in her death.

The family practitioner was grossly negligent in his care of the patient in the following: failure to maintain adequate and accurate medical records for the patient; failure to recognize that a cough and dyspnea can be signs of serious illness and failed to appropriately evaluate the patient’s condition or to maintain an appropriate differential diagnosis; failure to follow formal diagnostic protocol for diagnosing and stratifying new onset asthma in an adult patient, including obtaining a chest x-ray, a complete blood count, spirometry, and pulmonary function testing; inappropriately prescribing multiple courses of antibiotics without documenting the presence of a bacterial infection and without obtaining the patient’s informed consent to repeated courses of antibiotics; failure to recommend a chest x-ray for the patient and failure to document informed refusal of a chest x-ray; and lack of medical knowledge.

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

State: California


Date: October 2013


Specialty: Family Medicine, Internal Medicine


Symptom: Shortness of Breath, Bleeding, Cough, Weight Loss


Diagnosis: Lung Cancer


Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Failure of communication with patient or patient relations, Physician concern overridden, Improper medication management, Lack of proper documentation


Significant Outcome: Death


Case Rating: 5


Link to Original Case File: Download PDF



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