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.
Index Case 7
Ankle Injury
Testing and Treatment
Disposition
Billing
Return ED Visit
Outcome
Plaintiff Claims
Defense Response
Legal Outcome
Case Review
Documentation Review
This case concerns a young man with a seemingly benign injury, exotic travel history and a challenging diagnosis. The patient is a 30 year old man who checks into the ED with ankle pain. He had gone to an outpatient clinic, but was referred to the ED. The triage information including initial vitals are show here:
After triage, the patient was seen by the physician. The initial history and physical exam are shown below:
What testing would you order for this patient? How would you start treating them while waiting for results? Continue to the next page to see what was ordered.