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Endocrinology Sample Case 3.pdf  Endocrinology Sample Case 4.pdf

Over the next few months we will be adding more sample cases, covering all topics of Medical Malpractice.   Please check back very soon!

Endocrinology

• Poorly treated Diabetic For Eight Years, Increasing Risk of Heart Attack and Stroke which Occurred
  
  
• Hyperthyroidism and Graves disease (thyrotoxicosis) causing exophthalmos (bulging eyes), and treatment.
  
  
• An insulin dependent diabetic is sent home from an Emergency Room, and then hospitalized in a coma for weeks and has numerous complications including infections and bleeding.
  
  
• Woman 40 years old develops spontaneous hip fracture and then spine and pelvis fractures, all from non-diagnosed and non-treated severe osteoporosis.

Endocrinology: 

Poorly treated Diabetic For Eight Years, Increasing Risk of Heart Attack and Stroke which Occurred.

Concerning Dr. #1: Diabetes is a chronic disease and good control of blood sugar levels is essential to significantly reduce the risks of diabetes: heart attack, stroke, kidney disease, blindness, infection and advanced diffuse arteriosclerosis (hardening of all the arteries from cholesterol buildup).

When did this patient first come under the care of Dr. #1? The first record I have is from 2/10/ but is part of missing (previous) records. His fasting blood sugar (FBS) levels were periodically being monitored by Dr. #1. The first record of any blood sugar level was “FBS 160,” but the month is cut off on the copy. It was between 2/10 and 8/12. If it truly was fasting (which FBS denotes), it is way too high. It should be below 110 and ideally under 80. The only treatment was with the oral drug, “Diabenese 250 mg, 2 daily.” It was to be “checked in three months.”

The next note was 8/12 and the FBS was not recorded.

His blood pressure was not under good control either. The values eight years earlier were 150/100 – 160/110, but during that only office visit it was evaluated and decreased to 140/90 and 150/90 (borderline).

In the 8/12 note he was to be on a “stricter diet” because his FBS was too high. (This was by telephone; it was not an office visit. He should have been seen.)

The next office visit was noted to be (? month)/22 in the current time. Who was treating him for his diabetes and his blood pressure for eight years? The March 3, Emergency Room record from the Hospital said, “See your private doctor: Dr. #2.” Who is Dr. #2? Can he become a Defendant? Was he under the care of any other Doctor or Clinic those eight years? Check with his Medicare and other healthcare billing records. If he was seen, a bill certainly would have been generated.

Did the Hospital Emergency Room send a copy of their records to Dr. #1. Most Hospitals do this?

On ?/22, Dr. #1’s records note his blood pressure at 150/110, that he had “prostate surgery last year” (by whom and who evaluated him preoperatively for “clearance” for surgery, as is standard medical practice?). His blood sugar (diabetic) therapy was noted to be glyburide 5 mg b.i.d. (2 times per day). Was this now a new prescription? Who prescribed his diabetic medication for those missing eight years??? He had chest pain and no EKG was done. That is negligent, especially in a poorly controlled diabetic and hypertensive patient. It most likely would have been abnormal. Also, a cardiology referral was indicated as was an endocrinology referral (to evaluate and control his diabetes, which does not disappear with age; it gets worse, especially when subject to negligent care, which was “given” by Dr. #1).

On ?/23 (probably the next day) a FBS was 208. The only response was to increase the glyburide to three times per day. He required insulin over years since the oral therapy was not giving him good control, and whatever diet he was on was not effective with glyburide. Was he ever sent (with his wife) to a dietician by any Doctor? 

On ?/25 the right side of his body was feeling weak and he had slight chest pain. This required hospitalization, testing and therapy for an impending stroke and heart attack, was not done, and negligent.

On 1/25 (therefore all the ? months above most likely were January), his FBS was 264. 

On 1/29 his FBS was 170 (still way too high) and the only response of Dr. #1 was to prescribe two glyburide every A.M. and one and a half every P.M. and order a follow-up FBS in 30 days. This was way too long a delay.

On 2/28 the FBS was 229 and he gained five pounds in one month. Was this fluid retention? He was seen on 3/1. No physical exam for edema: pushing against the legs for indentation (“pitting”) was done. The EKG note was “neg" but no EKG is in the records (why?). And because Dr. #1 noted that the chest x-ray showed “increased hilar nodes” (enlarged lymph nodes next to the heart), he said, “consult (apparently with Dr. #3 on 3/7), but prescribed the steroid, Medrol, without any diagnosis of those nodes, in a patient who was coughing, had received antibiotics with no test for any sputum germs (culture and sensitivity), and in a diabetic where steroids markedly make the blood sugar go out of control and make control of infection very difficult. All this is negligent therapy.

On 3/3 he had nausea, vomiting and upper abdominal pain (also seen in heart attacks) and no repeat EKG was done, no Emergency Hospital Admission or Cardiology consultation arranged, and NO repeat blood sugar done. All this is negligent. He had a chance to acutely intercede and failed. He had eight years of opportunity to properly treat his diabetes, and miserably failed.

Blood clot “busting” drugs were available for years, and could significantly reduce the risk of mortality and morbidity if timely begun. Dr. #1 noted the pain began “after eating sausage,” but in this high-risk cardiac patient, did not do an EKG, which would be abnormal (as it was in the Long Hospital ER when it was taken at 1855: 6:55 p.m.) At what time had he seen Dr. #1 on 3/3? If therapy is begun within four hours of the onset of chest pain, the patient has the best chance for survival.

His blood sugar in the Hospital ER at 1752 (5:25 P.M.) was 492. That marked elevation was caused by the negligent steroid prescription by Dr. #1, and such a high blood sugar can increase the risk for a heart attack.

Dr. #1 knew his patient was at risk for arterial blockage, because on January 26 the head CT scan was abnormal showing “areas of ischemia (low arterial blood flow from partial blockage) or early infarction (total artery blockage causing death: gangrene of part of his brain).

Dr. #1’s negligent diabetic treatment significantly increased the risk of artery damage causing his stroke and fatal heart attack years before it would have otherwise occurred.

Obtain the missing records (EKG, Hospital #2 admission records, and from Dr. #2 as well as all other healthcare providers). Obtain copies of all pharmacy prescription from ten years through his death. Was an autopsy performed? Obtain the complete report. 

What specialty, if any, is Dr. #1? Supply his resume. Has he ever failed any Board Certification testing?

I also suggest review (after missing records are supplied) by an Expert in Endocrinology (diabetes management), Cardiology, and of the specialty, if any, of Dr. #1. How does he advertise in the Yellow Pages now and eight years earlier?

We look forward to continue assisting you and your Clients in this interesting case.

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Hyperthyroidism and Graves disease (thyrotoxicosis) causing exophthalmos (bulging eyes), and treatment.

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An insulin dependent diabetic is sent home from an Emergency Room, and then hospitalized in a coma for weeks and has numerous complications including infections and bleeding.

This 39-year-old patient was an insulin-dependent diabetic with many of the problems common to a diabetic, including eye, kidney, artery and nerve damage and marked increased susceptibility to infection.

She had many previous trips to the Emergency Room. She was seen on 1/18 and had a negative head (brain) CT scan, but was diagnosed with a sinus infection (the CT scan did not note any sinus problem). She was given a pain medication (narcotic, Demerol) injection. It was believed she was lethargic from this injection. She was given a prescription for an antihistamine (Claritin) and an antibiotic, which she never filled. I am missing the records from that critical Emergency Room visit.

On 1/19 she was comatose at home and taken to the hospital again. She remained unconscious her entire stay at Hospital #1 from 1/19 through 2/10. Her diabetes was out of control and was properly stabilized. She had a history of high blood pressure and on arrival at the emergency room it was very high at 210/120. It came down quickly to 190/100 although it was initially difficult to control despite proper intravenous drug therapy. The CT scan on 1/19 was normal, as was the CT scan of 1/21.

Her out-of-control diabetes was properly treated. The spinal tap was negative for meningitis. She had a severe bladder infection, which was treated. She was admitted to the Intensive Care Unit where she remained unconscious the entire hospital stay of three and one half weeks.

Multiple Specialists saw her and the Neurologist thought she had a stroke involving damage to her brain stem and other areas of her brain. Time is the only treatment. She also had diffuse pneumonia, which was treated correctly. Her chronic diabetic kidney failure worsened but stabilized.

She had an endotracheal tube inserted for ventilation and suctioning of her trachea (windpipe) and bronchial tree. Usually after five to seven days, if the patient is still comatose, a tracheostomy operation is done to gain direct access for a ventilation tube to be inserted. This was finally done on 2/4. Because of that previous indwelling endotracheal tube there was inflamed scar (granulation) tissue build up above her vocal cords which were not directly damaged. After a few months, that healed without any problem for her voice.

Because of her multiple problems and the negative brain CT scans, it was hoped that her comatose state would resolve when her diabetic state and all her infections would be fully stabilized (when the metabolic encephalopathy would be resolved). Therefore, there was some justification for the delay in doing the tracheostomy operation.

That operation was more difficult because of bleeding from her thyroid gland that was controlled with sutures. Afterward she developed bleeding at that site, which was very difficult to control and required insertion of an endotracheal tube and gauze packing, which was proper care. She developed DIC (disseminated intravascular coagulopathy, a free bleeding state from her infections) and received proper blood clotting fraction therapy and blood.

The family requested she be transferred to Hospital #2 where she remained from 2/10 - 4/7. She remained comatose for weeks. Their MRI was consistent with strokes, most likely caused by her high blood pressure weeks before. She had a severe diabetic problem with impaired emptying of her stomach (gastroparesis) which required the insertion of a feeding tube into her small intestine: J tube jejunostomy operation (on 3/12). That was removed a few months later.

When they evaluated her throat and trachea, they found only easily bleeding scar tissue in her larynx/posterior pharynx (throat above the vocal cords) and that healed spontaneously. The previous tracheostomy operation was correctly done. They did not "cut too deep."

Her pneumonia and fungal blood infection was very difficult to cure, but finally resolved. Her swallowing problem resolved. It was related to her diabetic nerve damage and stroke.

After she finally awakened and her overall condition properly stabilized, she was transferred to their Rehabilitation Hospital for physical therapy to help her regain her strength.

She developed severe lower intestinal bleeding and was transferred back to the main hospital where she was evaluated and treated from 4/8 - 4/21. No source of that hemorrhage was found despite detailed examinations. She was stabilized and properly treated.

She was again treated in rehabilitation therapy for the residual effects of her stroke and finally discharged on 5/13 after the jejunostomy tube had been removed. All of their care was good.

I have not seen all of the 1/18 Emergency Room records from the Hospital #1, other than the CT scan report. All of those Emergency Room records including the Nurses notes and laboratory reports need to be obtained in order for me to be able to give you my final opinion on that critical aspect of her care. The only information I had was what they say occurred there after she was hospitalized on 1/19.

If they should not have discharged her and/or improperly treated her on 1/18, then it probably was the proximate cause of her condition going out of control. This would also have been responsible for her entire lengthy Hospital stays where she eventually was brought back to most of her pre - 1/18 condition.

Her overall health status was precarious because she did not eat (and probably did not take her insulin) and her diabetes was out of control contributing to her coma and severe infections. Because she probably did not take her medication for her high blood pressure secondary to her nausea from her out-of-control diabetes, her blood pressure was dangerously high at 210/120. This directly contributed to her brain damage and prolonged coma, which caused her pneumonia requiring the tracheostomy (that bled) and the need for the prolonged bladder catheter that resulted in further bacterial and fungal infections, which were very difficult to cure. It also contributed to a temporary worsening of her chronic diabetic nephropathy (kidney failure).

Therefore, please obtain all those missing 1/18 records from her Emergency Room visit and care at Hospital #1.

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Woman 40 years old develops spontaneous hip fracture and then spine and pelvis fractures, all from non-diagnosed and non-treated severe osteoporosis.

The issue in this case is was there a negligent delay in diagnosis of the pubic bone (front of the pelvis) fracture in this 52-year-old woman, and what difference did it make? I will discuss her entire medical condition and care prospectively.

In 1984 she had a wrist (Colles') fracture, which was properly set. How did it occur? In 1987 she had a right hip fracture at age 40, which occurred when she "turned while getting out of bed and sustained an intracapsular fracture of the right femoral neck." This was reduced and held together by surgery, performed by Dr. #1 using five Knowles pins for internal fixation. After it healed, those pins were removed ten months later. All that is good care and not directly related to her pelvic fracture.

In 1990, at age 44, x-rays showed a healed right hip fracture but also: "the body of L1 with diminished vertical height (approximately 20%). The change is consistent with a degenerative compression deformity primarily."

It is most unusual for a woman in her young forties to develop a spontaneous hip fracture from turning getting out of bed, and also lose 20% of the height of the first lumbar vertebra. Her treating physician, who is unknown, and the orthopedic surgeon who performed the two hip operations, in my opinion had a duty to investigate directly, or by consultation with other physicians, why her bones were so fragile. This was not done and in my opinion, was negligent.

There are many causes of osteoporosis and reliable, safe and often effective treatments are available. This was not offered to her, and put her at higher risk for more fractures and the sometimes-chronic pain that may result.

In 1991 and 1992 she had episodes of back pain and sciatica (pinched nerve), which was treated with narcotics (Vicodin) and steroids. Steroids increase the risk of bone degeneration. In 1992 she also had "cervical syndrome" and "tennis elbow" for which she received more steroids and pain medication.

In 1995, Dr. #1 operated on her right hand for "trigger thumb," a tendon problem, and that care was good.

In 1996 she complained of severe left shoulder pain without trauma, for which she received more narcotics and steroids (another Medrol Dosepak).

On 6/2/98 she slipped on a concrete floor and sustained rib fractures which eventually healed under the care of Dr. #2, and time. One week later she experienced back pain.

On 7/9/98 she had right hip pain diagnosed as bursitis. On 8/6/98 she had back pain, was limping and also had left groin pain. They believed it was because she had favored her left hip secondary to right hip pain that also occurred when she fell on 6/2/98.

On 8/13/98 she had a "massive hematoma (blood clot in the flesh), left inner thigh, has grown since yesterday." They did not know its cause. No bleeding or clotting studies were done, and that would be negligent. However, they may have been normal, as some were thereafter.

On 8/13 she also correctly had x-rays of her pelvis, which showed no fracture and her back x-rays were unchanged from 1990. She also had a MRI of her lumbar spine, including her sacrum (tail bone area of the posterior pelvis), which was normal, but did not mention the rest of her pelvis. Perhaps it was misread by Dr. #3, the Radiologist at Hospital #1.

A whole body bone scan was done on 9/9/98 and revealed the healing rib fractures and no other fractures. Therefore, based on all the 8/13 reports and this study, most likely she did NOT have a pelvic fracture at that time.

On 10/1/98 she had continued back and left hip pain. Physical therapy was given. By 10/19 "patient is improving, and by 10/21 "walking much better." Physical therapy continued.

Because of the concern for cancer causing a spontaneous fracture of her pubic bone she had a needle biopsy on 12/23/98, which initially was suspicious for cancer. She saw Dr. #4, an Oncologist on 1/7/99, who concluded that it was not cancer. He noted that she saw Dr. #5 on 11/10/98 for the first time, a CT of her pelvis on 11/23/98 showed "she was found to have a left parapubic fracture," and an MRI on 12/17/98 of her pelvis showed "loss of bone about the left pubic symphysis" (the left half of the center of her pubic bone).

On 1/7/99 she was in so much pain, that she was unable to get on the examining table. "Any type of weight-bearing causes obvious severe pain."

On 1/15/99 Dr. #4 noted the patient and her daughter were surprised to learn for the first time that she had a pubic bone fracture.

On 1/21/99 Dr. #5, an Orthopedic Surgeon, believed that she had an "insufficiency fracture," was taking the female estrogen hormone Premarin (which is supposed to decrease the risk for osteoporosis which causes an insufficiency fracture), and that she had a hysterectomy. He ordered a bone density study (which should have first been done in 1987). This showed osteopenia of her lumbar spine and osteoporosis of her left hip (femoral neck), and severe osteoporosis of L4 (fourth lumbar vertebra). She was -2.71 standard deviations below normal for hip done density. The Radiologist recommended calcium with Vitamin D supplementation, weight-bearing exercise, estrogen replacement therapy (she was receiving this but at what dose and for how long?), and to avoid nicotine, and limit caffeine and alcohol.

On 2/17/2000 Dr. #6 at Hospital #2 noted that her pubic bone fracture was healing ("interval consolidation") and she was "undergoing strengthening and aquatic therapy," which is good care.

The records suggest that she had numerous cortisone (steroid) injections. What drug, what doses, when, for what reason, and by whom? They may be negligent, especially in a woman who was at much higher risk based on her hip fracture in 1987.

The concern for her "pelvic floor symptoms" from "long term weakness of the pelvic floor" (inside her vagina) would be related to vaginal deliveries and the hysterectomy, and not the pelvic fracture.

Pelvic fractures usually heal spontaneously in three months. No surgery or other therapy is used, just time and pain relief. So the fact that she did not know that she had this stress fracture from osteoporosis for a few months is irrelevant.

The fact that the bone scan was negative supports the absence of any pubic bone fracture on the pelvic x-rays and MRI from 8/13/98. She most likely developed it later, but either way, there is no direct therapy to heal it faster, just therapy to prevent it from occurring, as I noted.

The fact that she may have not had proper instructions and therapy to avoid osteoporosis and strengthen her bones, to reduce the risk of all fractures, including this pubic fracture is relevant, and negligent. Who was the Family Physician, Internist and/or Gynecologist who was treating her all this time and who wrote all those office notes without any identification? That should be the focus of this case.

I would suggest Experts in Orthopedic Surgery, Endocrinology and the same specialty as that unknown treating Physician.

I suggest that the patient be evaluated by a local Clinical Psychologist with courtroom experience for any residual emotional (psychological) damages. Administration of standardized tests such as the M.M.P.I. (Minnesota Muliphasic Inventory) which have been given to millions of people would further support that opinion before a jury.

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