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.

This case concerns a 33-year-old woman who presented to the ED with shortness of breath. She checked into the ED at 3:41am with respiratory symptoms. The patient had multiple visits to the ED and the staff knew her well.

Triage vital signs were obtained:

The patient gave a brief description of her symptoms to the triage nurse:

The nurse recorded the patient’s allergies and medications.

The patient had a complex past medical history. She had a history of diabetes (listed as both type I and type II diabetes in the record), nephrotic syndrome, end-stage renal disease on dialysis with a left arm AV fistula, gastroparesis, left eye blindness due to glaucoma, and diabetic neuropathy. Her surgical history included cardiac surgery for tetralogy of Fallot, a partial pancreatectomy that was reportedly done due to hypoglycemia, tubal ligation, and a partial thyroidectomy.

The physician’s documentation is shown below:

What tests would you order for this patient? Continue to the next page to see what was ordered and the test results!