Please click on the titles below to go to the corresponding sample Case Evaluation Reports.
The Antibiotic Prescribed For Acne Began To Cause Eye Damage From Brain Swelling And Was Not Discontinued. New!
At age 12, she was started on the anti-acne antibiotic Dynacin (minocycline) at Christmas 2000 by a Dermatologist, Dr. Laurie. Was she informed of the risks? When did she see him again?
On 1/12/01 she saw her Pediatrician, Dr. Michael, and complained of a headache for four days. On 1/13, she again saw him, and now also had nausea and vomiting. He used an ophthalmoscope and examined her retina (back of the eye) and found that the optic nerve was not normal. It had “? Ill-defined disc margins, ? Papilledema (swelling)” and “(optic) disc margin is ratty.”
Based on the above, he had a duty to take an adequate history (including new medications) and negligently failed to do so. He should have stopped Dynacin and most likely her symptoms would have subsided or have been more easily treated without surgery and severe vision loss.
He was further negligent in not immediately referring her to an Ophthalmologist and/or Neurologist (pediatric or adult).
Obtaining the MRI was good, but it was done without contrast, and may have been negligently interpreted by Dr. Goode. Obtaining a good copy (best is another one generated by their computer disc recording) for Independent Expert review.
A Physician who has found pathology cannot ignore it just because an MRI on the same date is interpreted as “normal MRI of the brain.”
She was hospitalized from 1/16-1/18 and no one ever did another funduscopic exam of her retina and optic disc. The “Primary Care Provider” was a pediatric medicine group. Dr. Ronald dictated the discharge summary on 1/18. He also performed the history and physical in which he noted she was taking Dynacin daily, and performed NO funduscopic exam. Dr. Michael also wrote an admitting note, which said re: January 13, “A funduscopic at that time showed ill-defined margins to her eyegrounds. Her (optic) discs were somewhat ratty looking (not a medical term) and somewhat ill defined." He did not re-examine her eyes, nor called for any in-hospital consultation for that purpose; further negligence. It would have shown progression.
The Hospital employee, Dr. Eric, did not do a funduscopic exam or note any concern regarding Dynacin. He saw her every day in the Hospital did nothing and was negligent.
On 1/18 Dr. Stephen, a Board Certified Child Neurologist, saw her and in his dictated three-page report of 1/18 did not do a funduscopic examination. That is grossly negligent. He noted she was taking Dynacin without comment or discontinuing it. That is negligent and still could have made a significant difference to her final need for surgery, re-operation and markedly impaired vision. He wrote by hand in the margin: "Addendum 1/25/01, fundi normal, venous pulsations seen on 1/18 exam."
That is not possible, because on 1/24 she had gross papilledema (marked swelling of the optic nerve disc), macular edema (swelling of the fine vision area of the retina) and hemorrhage. It could not have been "normal" on 1/18. Therefore, either Dr. Stephen falsified his record, or was negligent in the performance of the funduscopic exam, if he really did it. What do the patient and her mother recall? Also, obtain a copy of any of his handwritten notes from that visit.
On 1/25, Dr. Staci, an Ophthalmologist, found severe disease (as did the Optometrist, Dr. Harvey, on 1/24). He wrote to Dr. Michael with cc: to Dr. Stephen.
The spinal tap on 1/25 revealed a very high spinal fluid pressure, and after two spinal taps to try to lower the intracranial fluid pressure (which was causing the eye nerve damage), she was referred for a spinal fluid shunt (lumbar peritoneal) performed on 1/26 by Dr. Bryan and assistants. It was needed. Because the catheter (plastic tube) migrated (unfortunate), it was revised on 9/28.
Once the condition of the pseudotumor cerebri was diagnosed, the care was good. All Physicians and their Corporations and the Hospital that gave her care before 1/24 were negligent for all the reasons noted above. Their negligence caused and allowed her vision to be irreversibly damaged and required her to undergo the shunt operation, its revision, and potential future revisions.
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The Defense will contend she had a history of headaches, her mother had migraine headaches, and the MRI was negative. But the grossly abnormal ophthalmology exam Dr. Michael did on 1/13 was a red flag requiring immediate consultation, and discontinuation of Dynacin (a tetracycline), which is well known to cause pseudotumor cerebri (and therefore optic disc edema: swelling). Dynacin was not a life-saving drug. Each Doctor will probably point the finger of reliance on each other, but the optic disc pathology and gross progression from 1/13 to 1/24 is undeniable, and was untreated (no one stopped the Dynacin, as the first step).
I suggest you authorize the Medical Review Foundation, Inc. to have the following Board Certified Medical Experts review all the records: Pediatric Expert and an Ophthalmology Expert.
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Abusive Steroid Skin Injections in a Diabetic Patient, without Proper Sterile Technique Causing Severe Infections, not Timely Diagnosed.
According to the medical records, this patient was a borderline diabetic for one year. Steroid medications significantly affect diabetics and borderline diabetics. It makes their diabetes worse while under the effects of those steroids.
Based on that fact, a patient must be fully informed of that risk. In addition, steroids used other than for acute purposes pose a risk to the weight bearing joints (hips and knees) for a unique form of gangrene (aseptic necrosis). It also causes muscle wasting and significantly interferes with the immune system, making the risk of acquiring an infection much greater, and markedly interfering with the ability of the body to control and to cure such an infection.
The long acting steroids that are injected into skin lesions do get absorbed into the bloodstream and do have these "systemic" effects.
It is my opinion that the risks to her outweighed the benefits.
I do not believe she should have been given antibiotics with the injections. However, I feel that she should not have received these injections.
Furthermore, her skin should have been thoroughly cleansed with an antiseptic solution. In addition, proper sterility conditions were required, as I shall describe below. Because the same Staph aureus germ was involved in the three widely spaced abscesses, it is my opinion that the solution and/or device were not maintained in the sterile condition that is required.
Was the steroid medication from a multi-dose vial and was this the first patient it was used for? If not, how was the rubber stopper cleansed prior to each use, and was it kept refrigerated between uses?
In my opinion, the Doctor and not the Nurse should be using the "Dermajet" injecting device.
A skin biopsy was performed by Dr. #1 in his office. The pathology report is missing and needs to be obtained.
If, as you allege, the solution was spilled, then the Nurse is not competent to use the device and probably broke sterile technique.
On March 26, Dr. #1, an Osteopathic Physician (D.O.) Dermatologist used the Dermajet to inject lichenified plaques on her iliac crest (pelvic/hip bone area). He used Intralesional Triamcinolone at the dose of 40 milligrams/cubic centimeter (1/30 ounce). That is a standard concentration. What volume (which is proportional to the amount of steroid injected) was used each time?
You note that on May 7, one of the Doctor's Nurses used the Dermajet over 30 times to inject the Triamcinolone steroid into her hip, thigh and back areas. That is abusive.
As a Medicaid patient, how were they billed for these "services?"
When an injection is given, it is standard for the patient to be lying down so that if they get "lightheaded" or faint, they will not injure themselves. The Nurse injected her sitting, which is negligent, but the patient did not faint.
Pain coming two days after the injection (of this steroid, especially in a borderline diabetic) is pathologic and infection should have been considered since that is what it was. The patient said, "she feels that it has knots deep inside." This was a red flag that was not heeded. Dr. #1 noted she had tenderness but no overt signs of infection. He considered ordering muscle enzyme tests and they were normal the next week. He meant to order the serum aldolase too, but instead the next week ordered and received the serum amylase (pancreas gland) enzyme result (normal). He said: "I have no other explanation for her complaints," having felt that a steroid myopathy (muscle damage) was not reasonable.
On May 14, he ordered the muscle enzyme tests but did not order a Complete Blood Count (CBC) or blood sugar test. On her back, she had "a well demarcated thickened (lump) erythematous (red) area that is tender to touch with no epidermal (skin) changes" (except it was red). Was it hot? Pain and redness and a deep lump are consistent with an abscess. She should have been referred to a Surgeon for a second opinion. His explanation was "Arthropod (spider) bite, cannot rule out (r.o.) infection." The copy stamp "happens" to be over "cannot." "Spider bites," especially in a borderline diabetic who had been injected with steroids can be serious and should have triggered a consultation since he "cannot rule out infection." He prescribed the antibiotic Keflex at the standard dose of 500 milligrams but ordered it to be taken only twice a day. It should have been ordered every six hours, but a consultation was also needed to put a needle into it (aspirate) to see what was there (pus: germs and white blood cells). I believe his actions and inaction were negligent.
On May 28, "Patient presents with a very striking problem." She was red from her chin down all over her body. And "The arthropod bite versus infection on the back is now more larger (sic), somewhat fluctuant (fluid (pus) filled by feel), with an area of desquamation (skin loss) over the top." The infection was trying to drain itself. He was negligent for not immediately draining it or having her see a surgeon that day. The hip also "has some thickening and swelling in a localized area…denies any systemic toxicity." He must be blind. She was red all over and sometimes had a chill. That is systemic toxicity. She was not in shock. He concluded that "2. Staphylococcal scalded skin syndrome," which is from the Staph aureus bacterial germ poison and is "systemic toxicity," and continuing an oral antibiotic without draining is negligent care and led to worse infection and cosmetic damage.
On May 27, the previous day, she saw Dr. #2. Her temperature was 100.8 and her pulse was elevated to 120. Her respiratory rate was twice normal at 32. She diagnosed "abscess" and prescribed the oral antibiotic Cipro and noted she had a yeast mouth infection (from antibiotics) and prescribed an anti-yeast mouthwash drug. She failed to drain it or send her to a Surgeon. She and her clinic are negligent. Furthermore, she billed $35 for a Decadron (potent steroid) injection. This was neglicence on top of previous negligence.
She had previously seen Dr. #2 on April 29 and her pulse was 112 and respiratory rate was 32. Neither time did the doctor ever take notice of it, or its "systemic" significance, which is further negligence.
On May 30, a Healthcare Professional #1 saw her in Dr. #1's office and noted similar findings as May 28. But also said that the lesion on the back was "certainly fluctuant" and noted the previously documented "localized swelling on her left anterolateral hip." Their concern was for her to continue to take the antibiotic (which was not resolving the infection), and an abscess (fluctuance) must be drained in order to control and cure the infection, and the gross negligent failure of all to do or arrange for this as an urgency made it into a life threatening emergency, and cosmetic disaster for her. That was her last visit to that office, fortunately!
She was seen in the clinic office of Dr. #2 on June 3 with a pulse of 120 and they noted that the wound has opened, and her hip was tender. They noted she had "abscess back" and did nothing to aid her. It needed open deep drainage and the hip needed to be aspirated with a needle/syringe to diagnose it, and then it had to be drained.
The Complete Blood Count differential smear blood test on May 27 from Dr. #2's office was received in the laboratory on May 28, and it had "18% Bands" (normal is 0-5). These are immature white blood cells that pour out of the bone marrow to fight a very serious infection. I found no comment in their office records on this very abnormal test, further negligence.
On June 14, Dr. #3 saw her in the Hospital #1 Emergency Room and noted "…a very large abscess on the right gluteal and right outside of the thigh extending into the abdominal wall. This area is quite indurated (swollen), red and very tender." He opened the wound to drain it and said: "There was pus with a lot of air coming out. The patient has a lot of necrosis." This was a gas gangrene and he saved her life. That mass was "orange to softball size." Her pulse was 153 and respiratory rate was 40. She was septic (overwhelming infection almost putting her into septic shock, which is deadly). The culture was Staph aureus. She was immediately transferred to the Hospital #2 with intensive intravenous (by vein) antibiotics, en-route.
On June 15, she underwent a radical débridement (cutting out of dead and infected flesh) of her left thigh abscess which contained 300-400 cubic centimeters (10-13 ounces) "of frank pus."
On June 16, more pus was drained from the right thigh, the left thigh drainage site was repacked with gauze, and the back wound was opened further and packed.
The care at thes two hospitals was excellent.
The "care" by Dr. #1 and his Nurse, and by Dr. #2, her associate and her clinic office, were incredibly negligent, as described in detail above.
Once the infection was fully resolved, and after she was off all steroids (it had to be tapered so she would not go into steroid withdrawal shock), her diabetic state should return to its pre-existing state. However, it may be more difficult for her to use her exercise bicycle because of the thigh scarring. She should be examined by a local Doctor in Physical Medicine and Rehabilitation to assess that potential problem. Her foot problem resulted in some disability and decreased exercise and therefore weight gain. Usually if a borderline diabetic loses some of their excess weight, their type II diabetes will disappear.
We continue to remain available assisting you with this case and I would recommend that you authorize us, per our Fee Schedule, to obtain Expert opinions by a Dermatologist, Infectious Disease Physician, a Family Practitioner (re: Dr. #2), and a General Surgeon.
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Freezing (cryotherapy) of dark tumor on the ear that recurred, was a malignant melanoma, and spread (metastasized) to lymph nodes in the neck, from the incomplete treatment and the delay.
Malignant melanoma is a very dangerous form of skin cancer. It usually is pigmented (black, dark brown and/or purplish), can be flat or nodular (raised in bumps), and related to sun exposure.
If there is any question of the malignancy of a skin lesion, it should be excised (cut out), and that specimen sent to a pathologist for a microscopic analysis. The longer a malignant melanoma skin tumor is allowed to grow, the deeper it extends into and even beneath the skin. Blood vessels and lymphatic vessels (which drain the fluid from between the cells into lymph node filters, and then into the blood stream) become invaded by this growing cancer, which spreads to those lymph nodes, and even throughout the body via the blood stream.
On 8/4/98, Dr. #1 excised two skin lesions from the head of the patient. The "skin nevus" lesion he sent to the pathology laboratory for analysis. However, he did not submit the "dermal cyst" for pathological analysis. That is substandard care.
Then on 1/5/99, Dr. #1 treated the tumor in question negligently. His office records state: "Noted actinic keratosis left ear lobe. Cryotherapy (freezing the skin lesion) applied to actinic keratosis." No biopsy was performed. Therefore no pathologist was able to diagnose the lesion microscopically.
The next visit was on 2/19/99 and was for treatment of his hypertension. There is not one word discussing his ear and the healing of the lesion which was "frozen" to kill it six weeks before. That also is negligent care.
On 8/12/99, physician assistant #1, working with Dr. #2 noted: "This is a 44-year-old male for visit with lesion on the left ear present for years without much change. Now recently bled with fairly minor trauma." On the physical examination he said: "Lesion on ear pinna as noted." He referred the patient to a Surgeon.
Was this the same lesion that Dr. #1 froze, or a different one? Dr. #1 said it was on the ear lobe. When he was seen and operated upon by Dr. #3, he said: A 5 x 9 millimeter (25 millimeters = one inch) over the upper most portion of his left ear helix," on 9/1/99. And at Hospital #1 where he was referred, Dr. #4 noted it involved the "left auricle" of the ear, and the diagram shows its cross-hatched site to be at the upper outer edge of the left ear between the one and two o'clock positions. That is no where near the ear lobe.
Please have the Client and each witness prepare an affidavit with a separate photograph of his left ear attached for each with an arrow, signed by each person, to note with exact detail the location, size and color of the lesion treated by cryosurgery by Dr. #1 and the site biopsied by Dr. #3 and re-biopsied (if it was re-biopsied) at Hospital #1. Also supply the missing pathology and operative reports from Hospital #1 on this lesion and neck lymph nodes.
If Dr. #1 treated another lesion and did not see this one, he is also negligent. His negligence allowed it to grow and spread from 1/5/99 until 9/1/99, eight months.
If the lesion was "obviously" pathologic for years, then Dr. #1 was negligent on 8/4/98, 13 months before it was excised by Dr. #3, when he removed the "cyst from posterior scalp" and "mole from left scalp." What did the ear lesion look like on that date? Include that information in affidavits.
Does the patient have any pictures of him that may have been taken by family, friends or his employer that show the lesion(s) on his left ear? Did either doctor take a picture of it?
The lesion noted by physician assistant #1 was described as a "hemangioma." This is a blood vessel-like tumor which is reddish or purple in color.
The lesion was excised on 9/1/99 in a piece of skin that measured 1.3 x 0.8 x 0.5 centimeters (2.54 centimeters = one inch). This is also 13 x 8 x 5 millimeters. The pathology report does not mention the color but said: Pigment is noted deep within the tumor," yet he does not describe the surface pigment. The tumor reached the subcutaneous (below the skin) fat, which is a deep extension. She called it a Clark's Level IV and had a Breslow thickness of 3.12 millimeters. The "atypical melanocytes (melanoma cells) are noted extending to one margin of excision." Then it says: "The tumor is 1-2 millimeters from the nearest margin of excision."
The raw site received a full thickness skin graft from behind his ear, and it healed.
Dr. #5, an Oncologist (Cancer Specialist) referred him to Hospital #1. In his office report of 9/28/99 he said in broken English: "He noticed a lesion over the top of his left ear, maybe three years, maybe longer. He did not see any problem. He did notice some growth in it, was seen by local Physician and he start to freeze. He was aware that it was growing before it also, but he says after the freezing it may have seem grown more. Patient did notice a increase in size, it was nodular (bumpy surface), it was purplish in color. There was no pain. There was no bleeding."
This note does clarify the history, and if accurate, means that Dr. #1 was negligent on all of his visits for the reasons stated above.
At Hospital #1, an ultrasound (x-ray like study using sound waves) was positive for cancer spread into one or more lymph nodes in his upper neck.
They reviewed the microscopic slide from the excision by Dr. #3 and their pathologists (world renowned) concluded that it was a Clarks's Level V (deeper into the blood vessel flesh) and the depth of invasion was noted to be 3.0 millimeters (slightly less in thickness). They noted Dr. #3's biopsy site at the left helical rim (upper outer area).
What did the pathology report of the excised lymph nodes from his neck reveal? Did the melanoma cancer spread there as the ultrasound study concluded? That is also important for his future prognosis. What other therapy, if any, has he received besides interferon therapy? Was his ear re-biopsied again?
The deeper the melanoma growth into the skin (higher Clark's Level number) the worse the prognosis. It is highly curative at the Clark's Level I and decreases significantly. His prognosis is much worse at a Clark's Level V. The tumor can spread anywhere in his body and can have a growth spurt years later, causing disability and death.
Based on the medical records I have reviewed, it is my opinion that Dr. #1 was negligent, and his negligence significantly reduced the survival of the patient. Also, it probably made a difference concerning the need for major neck surgery with lymph node excision. Although opinions may vary on when to do that procedure, here the positive ultrasound mandated that surgery. (Supply that missing operative and surgical pathology report.)
Upon receipt of the missing records, affidavit clarification as requested and copies of any good photographs showing the tumor, I would suggest that we have these records reviewed by experts in Oncology, Radiation Therapy, and of the same specialty of Dr. #1 (General or Family Practice: Determine what exactly is his specialty and how does he advertise himself in the Yellow Pages).
The emotional damages can also be profound. I would suggest that he be examined by a local Clinical Psychologist (with courtroom experience), who can also administer the standard psychological tests which can serve as evidence in support of his opinion. Finally, a local Economist can evaluate the financial loss to him and his future estate.
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A mole was excised and eight days later the sutures were removed; the next day the incision opens up, is re-sutured, she develops chronic pain, has therapy and the scar excised.
At age 31, this female patient had an enlarging mole under her right scapula (shoulder blade) and there was a concern for malignant melanoma (aggressive skin cancer). An excisional biopsy was recommended. She signed a detailed informed consent which listed infection and re-excision as known complications, in addition to others. She also smoked, which can interfere with wound healing, and was a carpenter.
Surgery was performed by Dr. #1 and Dr. #2 on 10/7/97 under local anesthesia. The 3 x 1 centimeter (one inch = 2.54 centimeters) lesion was excised by a standard elliptical incision, as confirmed by the pathologist receiving a 1.6 x 6 centimeter ellipse of skin 0.9 centimeters deep. It was benign. No muscle was removed. It was a superficial excision.
On 10/15, eight days later, at the proper time, all the skin sutures were removed and the skin incision reinforced with paper tape strips (Steri-Strips). Again good care. The original incision had also been sutured on the inside with 3-0 chromic sutures which dissolve over weeks. This also is standard care.
The next day, she came to the emergency room with a wound (incision) dehiscence (separation of the previously sutured 8-cm incision). Did she return to work? Did she hurt her back? Did she remove the Steri-Strips? They properly irrigated the wound, sutured it closed (it did not appear infected), and as a precaution gave her an intravenous (by vein) antibiotic (clindamycin) as well as a prescription for a broad spectrum oral antibiotic (Cipro).
She returned to the Hospital #1 Clinic for follow-up care on 10/21. There was redness (erythema) and swelling (induration). She refused to tell them what antibiotic she was taking (she had nausea and vomiting) and refused to be seen by the doctor.
On 11/5, she was seen at the Hospital #2 with a small amount of wound drainage. They noted she had a history of an eating disorder (bulimia). Previously she was very anxious before and after the surgery for the mole. The wound was red and tender. They correctly prescribed hot compresses, a topical antibiotic (neosporin) and an oral antibiotic (Keflex), and instructed her to go to the surgery clinic the next day.
On 11/6, there was no sign of infection and she had a "well-healing wound."
On 11/23/97, she was seen at the Hospital #3 and she had two small stitch abscesses, but "nothing to I&D (incise and drain). She was correctly treated with antibiotics. No change was noted on 11/25, however, "she does seem to have a low threshold to pain…." She received intravenous antibiotics on 11/26 and 11/27.
On 1/22/98, she was assaulted, punched in the face and she fell over backward. She had low back pain.
On 3/23/98, she was seen at the Hospital #4 Emergency Room "complaining of pain upper back in area of scar after door struck scar one and a half weeks ago." There was a "question of scar neuroma" (inflamed piece of nerve trapped in the scar).
On 3/31/98, she had an injection of a local anesthetic and steroid (anti-inflammatory drug) injected into the scar. It was "excruciatingly painful, however, by the end of the procedure, the pain had subsided substantially as would be expected from local anesthetic."
On 1/8/99, Dr. #3 injected both medications deep into "trigger areas" (painful balls of muscle spasm) and adjacent nerves to block the pain. It too had a tentative effect, but justified revisional surgery to excise the scar and to directly insert these medications between her ribs to numb the sixth, seventh and eighth intercostal nerves. This was correctly done by him on 2/18/99. The Pathologist confirmed scar tissue removal.
Based on all of the above, this patient had an indication for surgical removal of her mole which was correctly done under local anesthesia. After eight days, the skin sutures were removed and Steri-Strips applied. The next day the wound split open and was resutured closed, and antibiotics were given. She developed a small local infection that was correctly treated and it resolved. Thereafter, she developed some chronic pain, made much worse by a new injury. Finally, the scar was excised and medication reinjected to try to control that local pain complication.
I do not see any substandard care as the proximate cause or contributing factor to her complications.
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Accutane for acne prescribed during pregnacy.
The acne treating drug Accutane can cause damage to a developing fetus. The standard of care requires that the treating and prescribing physician determine if the patient is at risk for being pregnant and warn her to take steps to prevent becoming pregnant while taking Accutane.
The basic inquiry consists of asking the patient if she is sexually active, and if so, what method of birth control, if any, she uses. Also, the physician must ask when was her last normal menstrual period (LMP).
If there is any question of pregnancy, the patient must be told not to take Accutane until a pregnancy test is done. The blood pregnancy test (HCG: Human Chorio-Gonadotrophic hormone) is usually positive a few days after conception. The urine morning pregnancy test usually become positive after two weeks.
Her Affidavit stated that she was 6 - 9 weeks pregnant on May 14. Those medical records should be obtained. Assuming that to be true, then on April 30, 1998 when she saw Dr. #1, she would have been 4 to 7 weeks pregnant and would have missed at least one normal menstrual period. Conception occurs at the time of ovulation which is approximately during the mid menstrual cycle (at about 15 days, plus or minus 4 days).
Therefore if she would have been asked when her last normal menstrual period occurred, it would have been more than one month before, which would be a "red flag".
Why did Dr. #1 order the blood pregnancy test? Why did the laboratory and/or the doctor delay until May 7 to get the results to the doctor? Who then called the patient?
Usually laboratory tests are run the day the blood is drawn if received early enough, or the next day, if not received on a weekend or holiday. When was the test run? Obtain all the relevant records from the laboratory including the "log in", testing, and reporting documents. How did they send the reporting documents? How did they send the reports to the doctor (by mail, courier with each pick-up, by fax)?
Assuming the truth of the Affidavit, then Dr. #1 was negligent by not determining the status of the existing pregnancy of her sexually active female patient, and warning her not to take the Accutane until the test results were known.
The doctor is also responsible for the actions of her office staff. Obtain all of Dr. #1's office records, as well as determining how she routinely received, reviewed and documented the laboratory test results she ordered, and what she and her staff did in this case.
Did the patient undergo an abortion? Obtain the records from her gynecologist and facility where the abortion occurred, including the pathology report on the fetus and placenta ("products of conception").
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I would suggest that you authorize us to have all the records (when you receive them) reviewed by one of our Experts in Dermatology. It may also be helpful to have an Expert Report by one of our consulting Gynecologists on the issue of causation.
You may want her examined and tested by a local Psychologist to document the extent of any emotional damages she sustained.
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