Received Event (Event Succeeded) Date: 2/23/01 Time: 10:45 AM Pages: 8 Sender: 850 414 1989 Remote CSID: 850 414 1989 ,, FEB 23-2881 18:51 AHCA/LEGAL MEDICAL 85@ 414 1999 P.@3 SJATE OF FI.ORIDA DEPARTMENT OF HEALTH DEPARTMENT OF HEAITH, ) PETITIONER, ) } CASE NO. 1998-03860 “ . ) CHARLES H. MOOREFILLD, Ll, M.D., } ) RESPONDENT. ME. ‘Tr -. COMPS NOW the Petitioner, Department of Health, hereinafter referred to as “Petitioner,” and files this Administrative Complaint before the Board of Medicine against Charles H. Moorefield, 117, M.D., hereinafter referred to as “Respondent,” and alleges: 1. Biféetive July 1, 1997, Petitioner is the state agency charged with regulating the practice of medicine pursuant to Section 20.43, Florida Statutes; Chapter 455, Florida Statutes, and Chupter 458, Florida Statutes. Pursuant to the provisions of Section 20.43(3), Florida Statutes, the Petitioner has contracted with the Agency for Health Care Administration to provide consumer complaint, investigative, and prosecutorial services required by the Division of Medical Quality Assurance, councils, or boards, as appropriate. 2 Respondent is and has been at all times material herein a licensed physician in the state of Florida: having been issued license number ME 0040364, Respondent’s last known address is 701 East Michigan Street, Orlando, Florida 32806. 3, Respondent specializes in Family Medicine, 4, On or about December 14, 1993, Patient D.W., a forty-seven year old male presented to the Respondent's office with complaints of “burning chest pain”, Respondent } : Received Event (Event Succeeded) Date: 2/23/01 Time: 10:45 AM Pages: 8 Sender: 850 414 1989 Remote CSID: 850 414 1989 FEB-23-2001 18:52 —___—:: ees=_s_scsasaeaee SS nn — a — — — — — — — —— — — — — — — — ———— — _ AHCA/LEGAL MEDICAL 858 414 1989 ordered a chest x-ray, which was interpreted as negative and noted that otherwise the chest was clear. Respondent's diagnosis was reflux esophagitis. Respondent prescribed Zantac 150 mg, _ bid#30 samples, with instructions to return for folow-up on December 28, 1993. 3 On or about December 14, 1993 Respondent failed to perform an adequate history and physical on Palicut D.W. given Patient D.W.’s past family history of coronary artery discase. past history of borderline hypertension, and past history of stress/anxiety attacks. The medical records do nol indicate a history or physical examination ever being performed by the Respondent. 6. On or about December 29, 1993, Patient D.W. retumed to the Respondent with complaints of anxiety attacks up to three (3) times a day. Medical records indicate that Patient D.W. was having thesc attacks when he was under pressure at work. These attacks were — characterized by symptoms of feeling shaky, muscle tension, muscle aches and soreness, restlessness, casy fatigability, feeling keyed up and on edge, exaggeracd startle response, difficulty concentrating at time when his mind goes blank, and trouble sleeping. Further, Patient D.W indicated at this visit that he was walcing up every two hours with symptoms of shortness of trealh, smothering scnsation, heart palpitutions, feeling sweaty, and having a dry mouth and frequent urination. 7. On about December 29, 1993, Respondent failed to perform an adequate history and physical on Patient D.W. given Patient D.W.'s past family history of coronary artery disease, past history of borderline hypertension, and recent symptoms. The medical records do not indicate a history or physical examination ever being performed by the Respondent. — Respondent’s assessment was amdely disorder for which he prescribed Buspar 10 mg., and _ requested a recheck of D.W, in two weeks. Received Event (Event Succeeded) Date: 2/23/01 Time: 10:45 AM Pages: 8 Sender: 850 414 1989 Remote CSID: 850 414 1989 FEB-23-2081 10:52 AHCA/LEGAL MEDICAL 858 414 1989 8. On or about January 6, 1994, Patient DW. retucned to the Respondent with complaints of still having sone anxiety attacks off and on but indicated he was feeling better. Respondent diagnose Patient 1).W. with depression and anxiety, discontinued the medication busper, and prescribed desipramine 50 mg, 1p.0, ghs #21. 9. On or about January 6, 1994 Respondent failed to perform an adequate histary and physical on Patient D.W, given Pationt D.W.’s past family history of coronary artery diseuse, past history of borderline hypertension, and past history of strew/anxicty attacks. The medical records do not indicate a history or physical examination ever being performed by the Respondent. 10. On or about January 24, 1994, Patient D.W. returned to the Respondent with continued symptoms of reflux, Respondent diagnosed Patient D.W. with reflux esophagitis. Respondent prescribed desipramine, a refill of zantac was prescribed, amd instructions ‘were given to return in three (3) weeks. 11. On or about January 24, 1994, Respondent failed to perform an adequate history and physical on Putient D.W, given Patient D.W.’s past family history coronary artery disease, past history of borderline hypertension, and past history of stress/anmsety attacks, The medical records do not indicate a history or physical examination ever being performed by the Respondent. 12 On or about Hebruary 17, 1994, Patient D.W. returned to the Respondent for follow-up. The medical records indicate thal Patient D.W. was sleeping better an: secms to be more energetic. Respondent noted in the meilical records that depression was much improved and reflux esophagitis was currently resolved. 13. On or about February 17, 1994 Respondent failed to perform un adequate history and physical on Patient D.W. given Patient 1.W.’s past family history of coronary artery disease, past history of borderline hypertension, and past history of stress/anxiely attacks, The medical 3 Received Event (Event Succeeded) rr Date: 2/23/01 Time: 10:45 AM | Pages: 8 Sender: 850 414 1989 Remote CSID: 850 414 1989 cea an un FEB-23-2061 18:52 AHCA/LEGAL MEDICAL 858 414 1989 P.@6 ’ records do not indicate a history or physical cxamination ever being performed by the : ; : Respondent. . 14, On or about September 25, 1994, Pationt D.W. suffered a myocardial infarction (heart attack) at home, and was transferred by advanced cardiac life support to Florida Hospital. Despite resuscitative measures, Pulient 1.W. was pronounced dead at 2:45 a.m. According to the \ ; official death certificate, and in keeping with the results of the Medical Examiner's autopsy report, oe the cause of death was listed ax: Acute Myocardial Infarction, due to (or as a conscquence of) hypertensive arteriosclerolic catdinvascular disease. The medical examiner also noted the existence of two other significant conditions, which contributed to Patient D.W.’s death, both cardiac in nature: cardiomegaly wxi small coronary artery syndrome, 15, Respondent practiced below the standard of care by not recognizing the risk factors of coronary artery discasc because he failed to get Palieat T).W.’s family history of Ss coronary artery disease, a past history of borderline hypertension, and « history of stress/anxiety attacks, 16. Respondent practiced below the standard of cure by not inquiring into Patient D.W’s family histury of coronary artery disease, a past history of borderline hypertension, and a past history of stress/arodety attacks, 17. - Respondent practiced below the standard of care by falling to perform an adequate 7 ao history and physical of Patient D.W. given his family history of coronary artery disease, past x ; history of borderline hypertension, and past history of stress/anxinty attacks. 18. Respondent failed to Keep adequate medical records in that they do not contain a 4 past medical, social, or family history given Patient D.W.'s past family history of coronary artery Received Event (Event Succeeded) Date: 2/23/01 Pages: 8 Remote CSID: 850414 1989 Time: 10:45 AM : Sender: 850 414 1989 FEB-23-2001 19:53 AHCA/LEGAL MEDICAL 85@ 414 1989 P.a7 : disease, past history of borderline hypertension, and past history of stress/amdely attacks or an adequate and complete plan of treatment. COUNT ONE 19. Petitioner realfeyex aud incorporates paragraphs one (1) through eighteen (18), as if fully set forth herein this Count One. 20. Respondent is guilty of gross or repeated malpractice or the failure to practice medicine with that level of care, skill, and treatment which is recognized hy 4 reasonably prudent ’ dmilar physician, as being acceptable under similar conditions and circumstances in that he failed to recognized the risk factors of coronary artery disease piven Patient D.W.'s family history of coronary artery disease, history of borderline hypertension, and history of stress/anxiety attacks. 21. Based on the foregoing, Respondent violated Section 458.331(1)(t), Florida Statutes, gross or repeated malpractice or the failure to practice medicine with that level of care, sla, and . treatment which is recognized by a reasonably prudent siller physician us being acceptablo under ar COUNT TWO : 22. — Petitioner realleges and incorporates purayraphs one (1) through eighteen (18) and paragraph twenty (20) as if fully sot forth herein this Count Two. 23. Respondent is guilty of failing to keep appropriate written medical records justifymg the course of treatment of Patient D,W. a8 they do not contain a medical, social, or family history : given Patient D,W,’s family history of coronary arlery disease, history of borderline hypertension, and history of stress/anxlety attacks and they du not contain an adequate plan of treatment. . 24. ‘Based on the foregoing, Respondent violated Settion 458,331(1}(m), Florida Statutes, failing to keep written medical records justifying the course of treatment of the patients, including, but Oe / Robert G Brooks, M.D., Secretary , a)

Docket for Case No: 01-000763PL