Welcome to medmalreviewer.com! The purpose of this site is to improve doctor’s medical knowledge and documentation by reviewing real-life malpractice cases. These cases are presented in long form, deep dive fashion, published monthly. Each case is broken down into several posts. To see more info about the website, here are links to the About Page and FAQs. Another helpful overview post is the 3 Goals of Documentation. I’ve created a Documentation Template to help doctors write notes that are easy to defend, and a Documentation Rubric to grade notes from malpractice cases.
Case 14: Leg Pain
This case concerns a 59-year-old man. Over the next pages we will follow his story from his PCP’s office, to a small ED, a rapid return to a larger ED, and ultimately to the ICU of one of the most prestigious hospitals in the world.
The relevant narrative begins on October 5, 2007. He scheduled an outpatient visit with his primary care doctor for leg pain. He was seen by a resident during this visit, as well as the supervising doctor. The symptoms in his legs included a sensation of pins and needles, numbness, and swelling in his ankles. He had a relevant past medical history of atherosclerotic disease and was a smoker.
His vital signs were reassuring. The physical exam noted mild leg swelling and tenderness to palpation in his left knee.
The doctor’s primary concern was for vascular causes, given his history, or peripheral neuropathy.
The resident and attending recommended starting aspirin, ordered labs, an EMG and a vascular consult.
The labs were ordered on an outpatient basis, therefore would not be available for a few days.
Continue to the next page to see his next visit.