A 62-year-old female patient presented in March 1996 to her long-time PCP with complaints of blood in her stool. A guaiac test in the office was negative. Her past medical history included hypertension, arthritis, peptic ulcer disease, obesity, and coronary artery disease. She had never received colorectal cancer screening. Based on a 20-year relationship that included frequently missed appointments, the physician believed she would refuse screening tests for colorectal cancer.
She returned in June with a complaint of abdominal pain. The physician prescribed an H2 blocker, Zantac, and noted a plan to obtain a right upper quadrant ultrasound if there was no improvement in her symptoms. The record does not indicate that a stool guaiac was obtained at that exam or if the patient was still reporting blood in her stool.
Failing to keep the next two appointments, the patient presented in August of the same year with improvement of her abdominal pain on Zantac and a stable weight. The patient was not anemic, and a CEA was within normal limits.
During the next two years the patient was seen for chest, abdominal and back pain, as well as hypertension She was treated with Biaxin and Prilosec for presumptive H. Pylori. Documentation was minimal in the visit notes, with no evidence of a comprehensive examination during this period or the years prior.
A visit on May 13, 1999 included a comprehensive examination. The physician noted a nine-pound weight loss, and a review of systems, including gastrointestinal and urinary, that he characterized as negative “in general.” Documentation does not include family history, although subsequent legal investigation revealed that the patient’s sister had died of colon and lung cancer in 1995. The patient had a pelvic exam during this visit, yet there is no documentation that a rectal examination was performed. Subsequently the patient had a screening mammogram. Lab results included low MCV/MCH; hemoglobin was 12.1, and hematocrit was 37 percent, both on the low end of the normal range and decreased somewhat from previous measures. Recommendations on the lab sheet suggest follow up to include additional hemoglobin and stool tests. However, the record does not indicate that this information was ever communicated to the patient.
The patient next presented to the practice four months later, on September 9, 1999, with complaints of a tooth infection. Care included assessment of her oral cavity, tooth, lungs and extremities. Follow up included a dental appointment and an appointment with her physician, which she did not keep. There is no evidence that the NP addressed the recommendations in the lab report from four months prior, including follow-up hemoglobin and stool tests.
In November, the patient went to the ED complaining of chest and abdominal pain. Chest X-ray was positive for pulmonary nodules and suggestive of metastatic disease. She died from metastatic colorectal cancer a month later.