STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
DEPARTMENT OF PROFESSIONAL REGULATION, ) BOARD OF MEDICINE, )
)
Petitioner, )
)
vs. ) CASE NO. 88-4913
)
SOHRAB AFSHARI, M.D., )
)
Respondent. )
)
RECOMMENDED ORDER
Pursuant to notice, a formal hearing was held in this case on February 23 and 24, 1989, in Jacksonville, Florida, before the Division of Administrative Hearings, by its designated Hearing Officer, Diane K. Kiesling.
APPEARANCES
For Petitioner: John R. Alexander
Senior Attorney
Department of Professional Regulation
130 North Monroe Street Tallahassee, FL 32399-0750
For Respondent: Harold M. Braxton
Attorney at Law
Suite 406, One Datran Center 9100 South Dadeland Boulevard Miami, FL 33156-7815
ISSUE
The issue is whether the medical license issued to the Respondent, Sohrab Afshari, should be revoked or otherwise penalized based on the acts alleged in the Administrative Complaint.
BACKGROUND AND PROCEDURAL MATTERS
Petitioner, Department of Professional Regulation, Board of Medicine, filed a one count Administrative Complaint alleging that Respondent violated Section 458.331(1)(t), Florida Statutes, by failing to practice medicine with that level of care, skill and treatment which is recognized by a reasonably prudent similar physician as being acceptable under similar conditions and circumstances. While that section also relates to gross or repeated malpractice, Petitioner acknowledged through counsel that Respondent is not charged with anything except practicing below the standard.
Petitioner presented the testimony of K.N., whose initials will be used throughout to comply with requirements of patient confidentiality. Petitioner also presented the testimony of Dr. James Corwin, Dr. Robert Moore, Dr. Kenneth Sekine, and Dr. A.E. Deeb by depositions admitted as Petitioner's Exhibits 3-6. Petitioner's Exhibits 1 and 2 were also admitted in evidence.
Respondent presented the testimony of Dr. Osvaldo Contarini, Joni Wood, Dr. Rafael Gomez, Dr. William Roger Wooden, Dr. Amir H. Fatemi, Dr. Daryl David Wier and Respondent. Respondent's Exhibits 1-5 were admitted in evidence.
Respondent moved ore tenus to strike the deposition testimony admitted without objection as Petitioner's Exhibits 3-6 on the ground that the witnesses were not offered as expert witnesses. Section 90.702, Florida Statutes, provides for opinion testimony by witnesses qualified as experts, however the opinion testimony is admissible only if it can be applied to evidence at trial. Here, Petitioner did not lay a foundation to qualify these four doctors as experts, nor were they tendered as experts. The depositions do contain information sufficient to show that each is a medical doctor and each is Board certified in a speciality. Hence, it appears that each is probably qualified to testify as an expert and the lack of additional qualifying information goes to the weight to be given to the expert opinions. Additionally, Respondent stipulated to the admission of these depositions and they were admitted without objection. At least some of these witnesses were available for live testimony, but were released to leave when the depositions were admitted. The Respondent did not move to strike the testimony until after the record was closed and Petitioner would be precluded from remedying the failure to further qualify these experts in their depositions. Therefore, the Motion to Strike is denied as having been waived and as being unfounded.
The transcript of the proceedings was filed on March 8, 1989. Proposed Orders were due on March 23, 1989. The time for filing proposed findings of fact and conclusions of law was extended to March 27, 1989, at the request of Respondent. Respondent filed his proposed findings of fact and conclusions of law on March 31, 1989. Petitioner filed its proposed findings of fact and conclusions of law on April 6, 1989, along with a Motion to Allow Late Filing. Considering that both parties filed their Proposed Orders late, the motion is granted and both parties' proposed findings of fact and conclusions of law are accepted for consideration. All proposed findings of fact and conclusions of law have been considered. A specific ruling on each proposed finding of fact is made in the Appendix attached hereto and made a part of this Recommended Order.
FINDINGS OF FACT
The parties stipulated to Findings of Fact 1-7 in their Joint Prehearing Statement.
Dr. Afshari is a general surgeon who treated the patient for injuries sustained in a boating accident.
The patient spent two days in the hospital.
The patient made three visits to Respondent's office.
While the patient was in the hospital, Respondent did not perform a vaginal or rectal examination.
On October 15, 1986, Respondent did perform vaginal and rectal digital examinations in his office.
During the vaginal and rectal examinations, the patient was positioned on her left side.
During the vaginal examinations Respondent did not use a speculum nor did he take any specimen.
The following Findings of Fact are based on the evidence of record in this
case.
Patient, R.N., a married female with two small children, was injured in a boating accident on October 2, 1986. "She and her best friend's daughter were taken to the emergency room at Baptist Medical Center where she was seen for the first time by Respondent.
Respondent is a Board Certified General Surgeon who practices as a trauma surgeon. A trauma surgeon is one who is on call from a hospital 24 hours a day for victims of acute injuries due to accidents and violence. He is licensed in Florida, having been issued license number ME 0036017.
Respondent is affiliated with nearly all of the hospitals in Jacksonville and is active at four hospitals, including Baptist Medical Center.
Upon his arrival at the patient's bedside, he immediately scanned her visually, checking her breathing, color, eyes and verbal communication. He noticed an overly tense, crying individual in apparent distress.
Respondent took a limited history of the accident and the patient's complaints. He did not take a complete history because at that time the emphasis was upon the patient's immediate complaints.
The patient's history should be taken at the earliest possible time. However, this does not necessarily mean at the hospital.
After checking the patient's heart, lungs and other essential areas, Respondent was assured that the trauma was confined to the upper torso.
He ordered the appropriate x-rays. The chest x-rays showed multiple fractures and blood or fluid around the lungs.
He also ordered a CAT Scan of the abdomen because the patient had three fractured posterior ribs where the rib cage envelopes the top of the spleen.
Because the patient was being monitored for possible head trauma, the only medication the patient could be given was something to take the edge off her pain.
Because of the type of trauma to the chest, Respondent diagnosed the possibility of a cardiac contusion. Cardiac contusion is a bruising of the heart caused from the momentum of the trauma to the chest area.
When such a contusion is suspected, the treating physician must institute a series of precautions designed to eliminate the possibility of a heart attack. The patient is placed on cardiac monitoring. The eyes are not
pressed upon nor is a tongue depressor stuck in the throat. More pertinently to the issues of this case, the treating physician does not dilate or manipulate any sphincter, most especially the rectal sphincter. Dilation or manipulation of the rectal sphincter can cause a drop in the patient's blood pressure which can put the patient in shock and disrupt the heart rhythm. This was the main reason Respondent did not perform a digital rectal examination of the patient while she was in the hospital.
It is not below the acceptable standard of care under the circumstances of this case for the treating doctor not to perform digital rectal and vaginal examinations while the patient is hospitalized.
It is the treating doctor who is the best judge as to what tests are to be performed and when they should be performed. It all depends upon the patient's signs, symptoms, complaints and the circumstances.
With no complaints referable to the rectal and vaginal areas, a trauma surgeon would not be expected to perform digital examinations to those areas, and especially not under the circumstances of this hospitalization.
The patient was placed on a heart monitor and a series of blood tests were performed to measure the different enzymes in her body to determine whether she did, in fact, suffer any cardiac injuries.
The admitting diagnosis was multiple trauma, blunt chest trauma and rule out cardiac/pulmonary contusions.
After spending a day in the Intensive Care Unit, the patient was transferred to another room, where she stayed for another day, and was discharged on October 4 with an appointment to see Respondent in his office on October 6, 1986.
The discharge diagnosis was blunt thoracic abdominal trauma, blunt chest trauma, multiple left posterior rib fracture, pulmonary contusion, plural effusion and anterior/posterior chest wall contusions. The two most prominent contusions were over the area of the fractures and upper right chest immediately under the clavicle extending to where the top of a bra would be.
The patient appeared for her scheduled October 6 appointment. She had never been to Respondent's office before. However, Joni Wood, Respondent's secretary specifically recalls this patient because Respondent had recently moved to her neighborhood.
The purpose of this visit was for Respondent to follow the fractured ribs. He was also aware that the patient was "not out of the woods" regarding the possibility of a cardiac contusion. Blood or fluid around the lungs within the thoracic cavity remained a potential problem.
The October 6 examination consisted of palpation and auscultation of the chest and upper abdomen because the patient was complaining of chest wall tenderness, aches and pains and inability to sleep. She was also upset over what had happened to her, her husband and her friend's child.
Respondent did not complete the patient's history on this visit because he knew he was going to see her again and she only had complaints referable to the upper torso injuries.
The patient was given another appointment for October 15, 1986.
On October 10, the patient called Respondent's office in apparent distress stating she was having difficulty breathing, had a tightness in her chest and thought she might have blood in her lungs that could lead to pneumonia.
She went to Respondent's office in a state of distress which was obvious to Joni Wood and the Respondent. She told Respondent that she had been told that blood in her lungs could lead to pneumonia and that she was scared that this could kill her.
After giving her the same basic examination as that given on October 6, Respondent assured the patient that she was suffering nothing more than an anxiety attack brought upon by the stress of the entire situation.
On October 15, the patient returned for her regularly scheduled visit. There were other patients in the waiting room when she arrived.
After the doctor, who had been at the emergency room of the hospital, arrived, he saw three or four patients first. The patient waited about one hour for the doctor.
The patient was met in the waiting room by Ms. Wood and the doctor. A friendly hug was exchanged by the patient and the doctor, and she was escorted into the examining room by Ms. Wood and Respondent.
Although the examining room opened to the waiting room, other patients were seated in such a way that they couldn't see into the examining room.
Ms. Wood laid a disposable paper drape out for the patient.
The patient sat at the end of the examining table. Respondent, while initially looking her over, began questioning her as to how she was feeling.
She responded by relating that she was sore all over, her chest hurt and she had discomfort when raising her arms. It would have been unusual for a patient with three broken ribs not to have complained about pain on this visit which was thirteen days after the trauma.
At this point, Ms. Wood left the examining room to answer the telephone. She left the door ajar. From her position speaking on the telephone, Ms. Wood could see into the examining room.
Respondent then listened to the patient's heart and lungs. He then had the patient untuck and partially unbutton her shirt and he began looking at the contusion on her upper chest wall which was entirely exposed. He also noticed the patient was very tense and anxious.
Respondent then palpated the chest wall contusion. This examination is proper and reasonable. Respondent did not do a breast examination.
It is not necessary to have a patient disrobe while palpating a contusion high on the chest wall. It is only necessary to expose the area involved and to palpate as far as is necessary in the treating doctor's judgment. The sitting position would be the proper position for this examination.
Respondent also began his "review of systems." The purpose of the review of systems is to inquire into areas that were irrelevant during the period of crises but necessary in order to complete the patient's history. Complaints are elicited from patients by their volunteering information or by questioning.
While Respondent was palpating the contusion, Ms. Wood returned to the room.
During this phase of the examination, the patient continued to sit at the end of the table and fully clothed.
The only significant response to the review of systems questioning was that the patient had been constipated, had hemorrhoids since the birth of one of her children, had rectal bleeding off and on and was having a vaginal discharge.
If there are complaints of bleeding, it is appropriate to perform a digital rectal examination when the complaints are first elicited even if the treating doctor is not a gynecologist. In fact, if symptoms were elicited, it would be poor practice and below the standard of the community for the doctor not to follow them up, especially in a trauma patient.
It is not below the standard of practice to perform rectal and vaginal examinations in the doctor's office.
Once again, Ms. Wood left the examining room to answer the telephone. She again left the door ajar and was positioned with a view into the room. She also remained within hearing distance.
The fact that the patient had been bleeding alarmed Respondent as this is significant to a trauma surgeon.
He then told the patient that he was going to check this out and asked her to lower her jeans and lie down.
Because she was uncomfortable on her back, Respondent had her lie on her left side facing the wall away from the door of the room.
She was struggling with her jeans, so Respondent aided her in lowering them to mid thigh. He then partially covered her with the disposable drape.
Respondent first visually inspected the rectal area, looking for cuts, bruises, contusions or other visual causes of bleeding. This is the usual first step in a rectal examination.
Seeing no visual signs, he then proceeded to perform a digital rectal examination to see if there was any bleeding.
It is not below the acceptable standard of care to perform a digital rectal examination while the patient is on her left side.
Respondent found no bleeding, but did discover that the patient had a moderate case of hemorrhoids and told her this.
Because he found no rectal bleeding, Respondent changed gloves and, while the patient was in the same left side lateral position, performed a
digital vaginal examination. Again, he was looking for signs of bleeding. He found a slight nonbloody discharge.
Although the classic position for a pelvic examination is with the patient on her back, it is not below the acceptable standard of care to perform a digital vaginal examination while the patient is lying on her left side when all the doctor is looking for is a bloody discharge. This position is called the Sims position and is commonly used.
When no blood is found rectally, it is up to the treating doctor whether he should go further in his examination. However, since some women confuse bleeding from the vagina for rectal bleeding, it was prudent of Respondent to check for blood in the vagina. Further, because Respondent was only looking for bleeding, it was unnecessary to use a speculum or to collect a specimen of the non-bloody discharge.
K.N. had many questions following this examination. Respondent asked her to wait until he had seen the other waiting patients so that he could answer all of her questions in his office.
After waiting for a short time, K.N. was called into Respondent's office. Respondent explained the various grades of hemorrhoids and the circumstances under which surgery would become necessary. He did not tell her that she had 4+ grade hemorrhoids and that she needed immediate surgery.
K.N. was tense and upset. During previous visits, K.N. had also been anxious, panicky and upset. She had complained of difficulty with sleeping. These are all symptoms of hyperthyroidism. Respondent realizes this while K.N. was sitting in his office. Visually it appeared that her neck was a bit protuberant.
Respondent palpated K.N.`s neck and felt an enlarged thyroid. He recommended that K.N. have a thyroid blood test and a thyroid scan.
R.N. became very upset and Respondent tried to calm her by arranging for the tests immediately.
Respondent had to return to the hospital to see an emergency patient, so he suggested that K.N. meet him at the hospital and he would personally schedule the tests.
K.N. met Respondent at the hospital. Respondent was able to schedule the tests for several hours later. K.N. did not want to wait that long, so Respondent suggested that she go have a drink, relax and come back.
K.N. was very offended because she assumed that Respondent meant an alcoholic drink and that Respondent meant the suggestion to include himself.
K.N. was wrong. Respondent eschews alcohol for religious reasons and would never have suggested that K.N. drink alcoholic beverages. Also, Respondent had further duties at the hospital and would never have asked a patient to have a drink with him.
K.N. was so offended that she left the hospital immediately, and refused to even speak to Respondent again.
It is recognized that K.N. testified that Respondent performed a breast examination of both breasts by feeling each breast under her shirt and
through her bra, performed the digital examinations with no drape and with no attendant present, inappropriately performed the digital examination with some form of sexual overtones, and told her she had grade 4+ hemorrhoids and needed surgery.
The testimony of K.N. is not found to be credible. While there is no reason to believe that K.N. is lying, there are numerous reasons to believe that she is confused and mistaken. Her version of the events in question is not accepted as credible evidence.
K.N. was examined by Dr. Robert C. Moore, a colon and rectal surgeon. Dr. Moore found grade 1 or 2 hemorrhoids. This finding is consistent with the findings of Dr. Afshari as stated in his office notes.
Dr. Kenneth Sekine examined K.N. approximately seven months after she last saw Respondent. Dr. Sekine found no palpable thyroid. However, this does not mean that K.N.'s thyroid was not enlarged on October 15, 1986, when Respondent examined her.
According to Dr. Rafael Gomez, a specialist in endocrinology, a person can have a mild cases of hyperthyroidism precipitated by stress and/or acute trauma and yet have the symptoms go away after seven months. Also, according to Dr. Gomez, Respondent's treatment of K.N. meets all standards of care and treatment. The opinions of Dr. Gomez are accepted as most credible.
According to Dr. William Roger Wooden, a Board certified specialist in obstetrics and gynecology, Respondent's care and treatment of K.N. meets all standards of practice, especially for a trauma surgeon practicing within his area of expertise. Dr. Wooden's opinions are accepted as credible.
According to Dr. Amir H. Fatemi, a Board certified colon and rectal surgeon, Respondent's care and treatment of K.N. meets all standards of practice. Even if Respondent had diagnosed K.N.`s hemorrhoids to be grade 4, in a significant percentage of cases, grade 4 hemorrhoids may dissolve and not exist on examination just 12 days later. Dr. Fatemi's testimony is accepted as credible.
According to Dr. Daryl David Wier, a general surgeon with a specialty in critical care medicine, Respondent's care and treatment of K.N. meets all standards of practice. It is noted that Dr. Wier is the only similar physician who testified in this proceeding. This testimony is accepted as credible.
The opinions of the four doctors who testified for Petitioner by deposition are given little weight because the opinions were based on facts not found to be true herein.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction of the parties to and subject matter of these proceedings. Section 120.57(1), Florida Statutes.
Petitioner charges Respondent with failure to practice medicine with that level of care, skill and treatment which is recognized by a reasonably prudent similar physician as being acceptable under similar conditions and circumstances, in his care and treatment of patient K.N., in violation of
Section 458.331(1)(t), Florida Statutes. Petitioner must prove this charge by clear and convincing evidence. Ferris v. Turlington, 510 So.2d 292 (Fla. 1987).
Petitioner makes allegations of facts which, as a course of conduct, fall below the requisite standard of care. Each fact alleged as part of the course of conduct will be discussed separately.
"During the hospital care of patient K.N., Respondent failed to perform a complete physical examination in that he failed to perform a vaginal or rectal exam." Considering the circumstances of this case, including the injuries suffered by K.N., the greater weight of the evidence is that Respondent correctly refrained from doing these examinations in the hospital. It was acceptable for Respondent to perform these examinations at the time he did.
"Respondent performed examinations of the breasts, vagina, and rectum on patient K.N. . . . These examinations were performed without the patient being disrobed and draped [sic] and without the presence of another person in the room." The facts are that no breast examination was performed. The only examination of the chest area was Respondent's examination of a contusion below the clavicle and above the bra line. Respondent's method of examination of the contusion was appropriate and met the standard of care. Additionally, there is no accepted standard of care that requires a female patient to be disrobed for a digital rectal and vaginal examination performed solely to examine for bleeding. Further, it has been found that K.N. was draped with a disposable paper drape and that such draping meets the standard of care. Finally, during the examination, Joni Wood did leave the room two times to answer the phone. Both times she left the door ajar, affording her a view of the examination without permitting other patients to see into the room. It is within the accepted standard of care for the attendant to leave the room during such an examination as long as she remains able to see and monitor the activities in the examination room. Respondent meets all of these standards of care.
"Respondent examined the patient's breasts during the aforestated examination by slipping his hands up under her shirt and palpating the breasts through her brassiere." Such a breast examination did not happen. Respondent appropriately examined a contusion as discussed above.
"During the aforestated vaginal examination, the patient was positioned on her side in an inappropriate manner." While it is true that K.N. was positioned on her left side, said positioning is an appropriate position for the examination, particularly in light of the purpose of the examination (to digitally look for blood) and the broken ribs suffered by K.N. which made a prone position painful.
"In addition, Respondent did not use any type of speculum, nor did he take any specimen to test vaginal discharge." There is no reason for a speculum to be used if a trauma surgeon is simply looking for bleeding. Additionally, there is no need for a trauma surgeon to take a specimen of a non-bloody vaginal discharge under the facts of this case. It would be totally inappropriate to apply the standard of care expected of a specialist in obstetrics and gynecology to a trauma surgeon. These are not similar physicians and the standard of care is quite different. Respondent met the standard of care applicable to his specialty.
"During the aforestated rectal examination, the patient was not positioned appropriately." There is absolutely no evidence to support this
charge. In fact, the patient was appropriately positioned in the Sims position, a position recognized and utilized by colon and rectal surgeons.
"Respondent failed to perform an endoscopic examination to properly evaluate patient K.N. for hemorrhoids." The facts show that Respondent did not do an endoscopic examination because none was necessary. Respondent was not attempting to evaluate hemorrhoids, but to explore for bleeding. Respondent is not a colon and rectal surgeon. If he determined that the patient had significant hemorrhoids which needed further examination, he would have referred her to a colon and rectal surgeon for an endoscopic examination.
"Respondent inappropriately advised patient K.N. that the hemorrhoids would need surgical intervention." The credible evidence is that Respondent did not advise K.N. that her hemorrhoids needed surgical intervention. This allegation is not supported by the evidence.
"Respondent failed to perform a thorough examination and failed to assess the clinical signs and symptoms of hyperthyroidism." Respondent, in fact, performed an adequate examination for hyperthyroidism by evaluating K.N.'s signs of hyperthyroidism (anxiety, sleep difficulty, panic), by visually examining the neck, and by palpating the thyroid. The next step would be blood tests and a thyroid scan. Respondent ordered these tests and scheduled them for the same day. Respondent's examination was appropriate and met the standard of care.
"Respondent failed to order appropriate laboratory studies to document hyperthyroidism." Respondent, in fact, ordered the appropriate tests. The charge is total unsupported.
"Respondent inappropriately advised patient K.N. to undergo a thyroid scan." Petitioner's allegations are nonsensical. First it says Respondent failed to assess hyperthyroidism and failed to order appropriate laboratory studies, then it says he inappropriately ordered those same
tests. In fact, Respondent appropriately ordered the thyroid scan and he entirely met the standard of care in this regard.
Petitioner failed to carry its burden of proving any of its allegations by clear and convincing evidence. The clear and convincing evidence is that Respondent's care and treatment of K.N. met all applicable standards of care and that Respondent practiced medicine with that level of care, skill and treatment which is recognized by a reasonably prudent similar physician as being acceptable under similar conditions and circumstances. All charges should be dismissed.
Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Department of Professional Regulation, Board of
Medicine, enter a Final Order dismissing the Administrative Complaint against
Sohrab Afshari, M.D.
DONE and ENTERED this 17th day of April, 1989, in Tallahassee, Florida.
DIANE K. KIESLING
Hearing Officer
Division of Administrative Hearings The DeSoto Building
1230 Apalachee Parkway
Tallahassee, FL 32399-1550
(904) 488-9675
Filed with the Clerk of the Division Administrative Hearings this 17th day of April, 1989.
APPENDIX TO THE RECOMMENDED ORDER IN CASE NO. 88-4913
The following constitutes my specific rulings pursuant to Section 120.59(2), Florida Statutes, on the proposed findings of fact submitted by the parties in this case.
Specific Rulings on Proposed Findings of Fact Submitted by Petitioner, Department of Professional Regulation, Board of Medicine
Each of the following proposed findings of fact are adopted in substance as modified in the Recommended Order. The number in parentheses is the Finding of Fact which so adopts the proposed finding of fact: 1(9).
Proposed findings of fact 2, 3, 5, 6, 7, and 9 are subordinate to the facts actually found in this Recommended Order.
Proposed findings of fact 4, 11, and 13 are rejected as being irrelevant.
Proposed findings of fact 8, 10, 12, and 14 are rejected as being unsupported by the credible, competent and substantial evidence.
Specific Rulings on Proposed Findings of Fact Submitted by Respondent, Sohrab Afshari, M.D.
Each of the following proposed finding of fact are adopted in substance as modified in the Recommended Order. The number in parentheses is the Finding of Fact which so adopts the proposed finding of fact: 1-21(8-28); 23-38(29-44); 40- 56(45-61); and 58(62).
Proposed findings of fact 22 and 39 are unnecessary.
Proposed finding of fact 57 is subordinate to the facts actually found in this Recommended Order.
COPIES FURNISHED:
John R. Alexander Senior Attorney
Department of Professional Regulation
130 North Monroe Street Tallahassee, FL 32399-0750
Harold M. Braxton Attorney at Law
Suite 406, One Datran Center 9100 South Dadeland Boulevard Miami, FL 33156-7815
Harper Fields General Counsel
Department of Professional Regulation
130 North Monroe Street Tallahassee, FL 32399-0750
Dorothy Faircloth Executive Director Board of Medicine
130 North Monroe Street Tallahassee, FL 32399-0750
| Issue Date | Proceedings |
|---|---|
| Apr. 17, 1989 | Recommended Order (hearing held , 2013). CASE CLOSED. |
| Issue Date | Document | Summary |
|---|---|---|
| Jun. 13, 1989 | Agency Final Order | |
| Apr. 17, 1989 | Recommended Order | Level of care recognized by reasonably prudent similar doctor and whether Doctor met that standard are questions of fact. |
DEPARTMENT OF HEALTH, BOARD OF NURSING vs ELIZABETH BRADLEY LEVETON, R.N., 88-004913 (1988)
DEPARTMENT OF HEALTH, BOARD OF NURSING vs STEVEN PATRICK GARTH, R.N., 88-004913 (1988)
DEPARTMENT OF HEALTH vs ANABEL RODRIGUEZ, R. N., 88-004913 (1988)
DEPARTMENT OF HEALTH, BOARD OF NURSING vs BARBARA J. REUTZEL, RN., 88-004913 (1988)
DEPARTMENT OF HEALTH, BOARD OF NURSING vs KARI MIKULANEC, R.N., 88-004913 (1988)
