Complex Medical Record
Review / Chronology

We routinely identify new issues and clues to missing or withheld important documentation in medicals received for review from our clients. We suggest fruitful avenues for further research. We can point the way to further resources for expert testimony. Let us provide you with the clarity you need to manage your complex medical file. We do the in-depth review that will bring your litigation and deposition preparation to new heights!

Sample Liability LCP

Complete Nursing Assessment and Life Care Plan (Link)
This link opens a redacted Life Care Plan for a product liability case involving gadolinium-related nephrogenic systemic fibrosis. Excerpts are below:

Diagnosis:
Mr. Smith is a 56-year-old male with chronic renal failure and nephrogenic systemic fibrosis. NSF is characterized by fibrosis (thickening) of the skin, joints, eyes, and internal organs. Patients develop large areas of hardened skin with fibrotic nodules and plaques; the skin is often described as "woody."" At the time of my visit I found that his left forearm felt like warm marble, hard and absolutely unyielding. The mechanism at the cellular level is not fully understood; the disease was first seen in patients with renal failure on hemodialysis. It was described in the literature as a skin condition in 2000.[1] Later research associated the condition with gadolinium used in diagnostic imaging; more severe effects were described in patients with more severe metabolic acidosis and higher gadolinium load.[2] Limits on gadolinium use in patients with renal failure were included in published safe practices from the American College of Radiology in 2007. [3]

Summary of Medical Care
According to records received for review, in November 2006 Mr. Smith began to notice skin hardening and swelling in his left forearm and hand. Over time this developed in his upper arm and fingers, right arm, lower legs, ankles, and feet and has been accompanied by loss of range of motion, pain, and the characteristic woody appearance and feel of the skin seen in NSF, which was diagnosed in early 2007. He was seen by several specialties including the behavioral health unit at City Medical Center, a pain clinic, and a dermatologist. He was also seen regularly by a vascular surgery service for significant arterial disease (treated with stents and allografting) thought to contribute to the chronic wound on his shin, which occurred when he fell at home,. He received home care for this wound, but this has presently stopped. He states that for some time that he was seen in his home by a physical therapist from a visiting nurse association, but states this stopped Òsome time agoÓ reportedly because his income level was too high. He changes the dressing on his leg wound himself. Note that visiting nurse services are usually restricted to persons who are homebound; Mr. Smith is able to travel out of the home to dialysis and medical appointments. There are also no VNA records to review that might clarify this. Most recently, Mr. Smith sustained a fractured tibia in a mishap with his power scooter. This is at high risk for nonunion due osteomyelitis; he reports that amputation has been recommended but that he refuses this.

[1] Scleromyxoedema-like cutaneous diseases in renal-dialysis patients, Cowper SE, Robin HS, Steinberg SM, Su LD, Gupta S and LeBoit PE The Lancet, Volume 356, Issue 9234, 16 September 2000, 1000-1001

[2] Nephrogenic fibrosing dermopathy associated with exposure to gadolinium-containing contrast agents-- St. Louis, Missouri, 2002-2006 Morbidity and Mortality Weekly Report. 2007 Feb 23;56(7):137-41.

[3] ACR Guidance Document for Safe MR Practices: 2007 Kanal E, Barkovich AJ, et al of the ACR Blue Ribbon Panel on MR Safety AJR 2007; 188:1447-1474

Sample Chronology:

"On September 7 his platelets continued to decrease, but more importantly, his clotting worsened significantly. Bruising spread to the right arm. The medication to decrease clotting was now discontinued. On May 18, the hematologist/oncologist recommended stopping all heparin products and checked for anti-platelet antibodies (found to be negative). Pleural effusion was still present on daily chest films. "On September 9 he developed what appears to be oral candidiasis, a yeast infection, perhaps as a result of immune suppression from the ongoing anti-inflammatory steroids. He had increasing nausea, worked up by a gastroenterology consult, and ultimately attributed to constipation, medications, and his neurological condition. Nausea resolved with aggressive laxatives and medications for nausea and a planned endoscopy was canceled. He felt weak and expressed fears that he was going to die; he was described as with a flat affect. No psychological consult was made; nursing notes are scanty on this issue regarding any interventions beyond the single words, 'support' and 'listening.' "By September 14 Mr. Jones was considered ready to transfer to the ABC Hospital's acute rehabilitation unit for therapy related to his deconditioning and weakness. He had failed voiding tests several times and had a Foley catheter in place that he refused to have removed again, pending urological work up. His chest x-ray of September 10 showed persistent effusion, now with left lung volume loss. Chest x-ray of September 14 showed effusions characterized as 'loculated,' a term meaning, 'divided into compartments,' which is often used to describe areas of collections of pus. No notes are found which reflect any action regarding this worsening finding. "Dr. Primary, PCP, wrote the discharge summary. He notes that Mr. Jones (direct quotes): Became hypotensive from dehydration Went to ICU Improved Developed pulmonary emboli and atrial fibrillation Was started on heparin and warfarin (anticoagulants) PTT & INR (clotting studies) excessively elevated Developed a hematoma in the left flank from the incision Needed transfusions for blood loss related to this To rehabilitation for OT/PT before planned discharge home "In this note, Dr. Primary makes no mention of specialties consulted, meningioma, depression, GI problems, ongoing chest findings, urinary issues, severe hypoproteinemia, or sepsis." This patient was returned to the acute hospital in grave condition after an unknown period in the rehabilitation unit (missing records) and a few weeks at home. Two days later he died in the operating room after massive chest bleeding, sepsis, and cardiac arrest. Many records were determined to be missing, including all rehabilitation unit notes, nursing notes, cardiac arrest sheets, point-of-care lab values, anesthesia records, and diagnostics for several inpatient stays.

(508) 564-9556
(866) 604-9055

Call Us Today-

Put your trust in our experienced health care consultants for professional life care planning services.

Howland Health Consulting | 508-564-9556 | Contact Us