Failure to diagnose and treat fungal infection

Laura Hale Brockway

Presentation

A 7-year-old boy, accompanied by his mother, came to a dermatologist for treatment of a scalp condition. His history included pulmonary valve stenosis, contact dermatitis, impetigo, and tinea capitis. At this visit, the patient had large areas of scaly plaque on his scalp.

Physician action

After visual examination, the dermatologist diagnosed the condition as tinea amiantacia (sebopsoriasis of the scalp) and prescribed three topical steroid medications: salicylic acid shampoo to be used daily; salicylic acid foam applied after the shampoo; and clobetasol propionate foam to be applied twice daily.

After applying the treatment, the mother reported to the dermatologist that the patient’s condition had worsened. He was now experiencing increased pain and larger, inflamed scabs and bumps on the scalp.

When asked if she was following the treatment plan, the mother reported that she was only able to fill and use two of the prescribed medications. She claimed the dermatologist yelled at her, and urged her to use all three prescriptions.

The mother asked the dermatologist to see her child due to the worsening condition, but the dermatologist told her to wait until a previously scheduled appointment in three weeks.

The mother obtained the other medication and applied it as prescribed. The patient’s condition worsened. The patient’s mother called the dermatologist’s office and asked for her son to be seen immediately. According to the mother, she was told there were no earlier appointments available.

The patient’s mother took him to the emergency department (ED). He was diagnosed with a fungal infection and prescribed a different medication. The mother reported that the ED physician told her that the medications prescribed by the dermatologist made the fungal infection worse.

The child was left with scarring of the scalp and alopecia.

Allegations

A lawsuit was filed against the dermatologist. The allegations included:

failure to properly evaluate and examine the patient’s scalp, nails, hair, and skin;
failure promptly follow up and re-evaluate the patient when worsening symptoms were reported;
failure to properly treat the patient’s condition; and
failure to maintain an adequate medical record.

Legal implications

Three dermatologists reviewed this case for the defense. Two of the physicians were supportive of the dermatologist’s care, but noted that a complete medical exam or a documented exam of the patient was missing. The third physician was critical of the dermatologist for failing to perform any lab work to confirm the diagnosis of tinea amiantacia.

The plaintiff’s expert was critical of the dermatologist for misdiagnosing the scalp condition and for failing to immediately reassess the patient. Other criticisms included the failure to perform any tests to confirm the diagnosis and the failure to change medications once informed of the patient’s worsening condition.

Disposition

This case was settled on behalf of the dermatologist. The patient’s mother also filed a TMB complaint against the physician.

Risk management considerations

The defendant physician offered no explanation in the medical record for his diagnosis. Although defense consultants stated there is a simple way to rule out a fungal infection, the physician relied on a visual exam. The patient was misdiagnosed and prescribed a medication that was contraindicated.

When the patient’s mother called the practice to report worsening symptoms, staff failed to make an appointment for the patient. The mother then sought care for the patient at the ED. When patients call to report that a treatment is not working, it would be prudent to document the specific complaint and how the practice responded to the patient.

Complete and accurate records are not only best practice, but are essential in the defense of a medical liability claim or complaint before the Texas Medical Board (TMB). Accord- ing to the TMB rules, physicians are required to maintain an adequate medical record that is complete, contemporaneous, and legible.

TMB Rule 165.1 provides a set of standards for a record to be considered “adequate,” in- cluding, but not limited to, reason for the encounter, physical exam findings, assessment, past and present diagnoses, and decisions that substantiate the plan of care. In addition, the rules specify that medical records should “include a summary or documentation memorializing communications transmitted or received by the physician about which a medical decision is made regarding the patient.” This would include telephone call documentation. (1)