This month’s case addresses the issues of when to act on abnormal test results, and when to inform patients about such results. In the case, a jury ultimately faulted a physician for failing to follow up or notify a patient about a urine test result that was only marginally over the reference range.
Dr A was a primary care physician with his own practice. He first saw Mr N when the 50-year-old patient came in after a work screening indicated he might be suffering from hypertension. The doctor noted that Mr N suffered from hypertension, was obese, admitted to smoking a pack of cigarettes a day, and said he had occasional sciatica.
As part of the workup, Dr A did a urine dip test which showed blood in the urine. Dr A did not mention this to the patient but scheduled him for a full physical in a month. In the meantime, Dr A sent the urine sample out for microscopic analysis, which revealed 2-3 red blood cells. The reference range was listed as 0-2. Dr A considered whether he should notify the patient but decided against it. Mr N was returning in a month and he would do another urine dipstick test then. The fact that the results were just barely above the reference level bolstered his confidence in waiting to take another urine test next month.
The following month Mr N returned for his physical. Dr A did another urine screening dipstick test, but this one was normal and showed no blood in the urine. Reassured that there was not a problem, Dr A did not bother to notify the patient that his result had previously been abnormal.
Two years later, Mr N switched PCPs. His new physician, Dr B, gave the patient a urine dipstick test which came back positive for blood in the urine. A microscopic analysis of the sample showed 2 red blood cells per high powered field. Dr B told the patient about the hematuria and asked if he had been alerted to it before. Mr N stated that he had not been told about blood in his urine by his previous physician. Dr B referred Mr N to a specialist for further testing and made a note to request the previous doctor’s records.
When hematuria was found by the specialist, Mr N was sent for a full workup including imaging of his kidneys. A cancerous mass was discovered which was diagnosed as renal cell carcinoma. Meanwhile his previous records from 2 years had been requested and that first instance of hematuria was discovered.
Mr N had his kidney removed, but it was determined that the cancer had spread beyond the kidney, to the lymph nodes. Despite treatment, the cancer spread to Mr N’s liver, lungs, and brain. He died 3 years after his diagnosis, 5 years after he had seen Dr A.
Mr N’s family was devastated and confused by the medical records which seemed to indicate that Mr N had hematuria 2 years before his diagnosis which had not been acted upon. They sought counsel from a plaintiffs’ attorney. After reviewing all the records, including the initial records from Dr A which indicated hematuria but had no follow-up or note that the patient was ever alerted, the attorney took the case. He sued Dr A, claiming that the delay in diagnosis caused by his failure to follow-up on the first abnormal dipstick result deprived Mr N of getting treatment at an earlier stage when the cancer could have been curtailed.