Attachment A - WSEC Sample.docx

Veteran Last Name Internal Medicine/Primary Care Date:

Written Summary and Evaluation of Care (WSEC)

COVER SHEET

OMLA Notification Number:

CPP Name:

|X| The CPP did attest that the patient’s medical and other records were reviewed in rendering this determination.

Veteran’s Name: xxxxxxxxxx

Date of Birth: xx/xx/xxxx

Involved VA Facility(s): XXXXX VAMC

Allegation: Failure to diagnose and refer to nephrologist forced Veteran to seek out private care where he was treated for kidney failure due to Stage 4 Chronic Kidney Disease and renal cancer.

List of Review Materials provided by OMLA:

Medical records from XXXXXX VAMC Number of CDs with imaging studies: 0

Practitioner Statements:

Xxxxxx xxxxxx, MD-Primary Care-Statement dated XXXXX.

Xxxxxx xxxxxxxxxx, NP-Statement dated XXXXX.

SUMMARY OF CARE

Brief Summary of Incident:

59-year-old Veteran who had an elevated prostate specific antigen on xx/xx/xxxx and was diagnosed with and treated for prostate cancer. The Veteran was also having hematuria and an elevated creatinine level that was noted during routine bloodwork on xx/xx/xxxx. The Veteran was regularly seen by primary care provider and urology. On xx/xx/xxxx, the Veteran was admitted to a non-VA hospital due to rapidly progressive glomerulonephritis and was then followed by nephrology. The Veteran was treated for the rapidly progressive glomerulonephritis and was continued on Imuran for maintenance treatment.

Pertinent Past Medical History:

59-year-old Veteran with past medical history of elevated prostate specific antigen, hypertension, degenerative arthritis, obesity, hyperlipidemia, low back pain, diabetes mellitus and chronic fatigue syndrome .

Chronology of the Episode of Care:

The patient’s name:

The patient’s age at the time of incident: 59 The patient’s gender: Male xx/xx/xxxx 18:50 Test Results Letter by XXXXXX xxxxxx, MD. I am writing to give you result from your lab test done on xx/xx/xxxx. Your PSA, which checks for signs of prostate cancer was 5.55 (5.08 on xx/xx/xxxx). Normal for patients 50 to 60 is below 3.5. Please keep the xx/xx/xxxx Urology appointment. Your future appointments are as follows: xx/xx/xxxx 11:30 CAT SCAN (sic) xx/xx/xxxx 08:00 URO RETURN (sic).

xx/xx/xxxx 10:50 Lab results: Creatinine 1.4 H. (ULN 1.2). GFR 54 (NL>60). Urine blood: 3+, protein 2+, RFC/HPF 14.

xx/xx/xxxx 14:53 Physician Progress note by XXXXXX xxxxxx, MD. Presents for follow-up visit. No major health issues reported during this encounter. Assessment and plan: Type II diabetes mellitus: HGB A1C 6.9 on XXXXX; at goal. Osteoarthritis: Stable. Hyperlipidemia: LDL 92 on xx/xx/xxxx. On statin regimen. Hematuria / Elevated PSA: Scheduled on xx/xx/xxxx for biopsy; patient is aware. Check UA/UC. 6) Obesity: Declined dietary counseling. 7) Health maintenance: Will bring colonoscopy report. I reviewed and discussed the xx/xx/xxxx lab results with the patient. Follow-up 6 months.

xx/xx/xxxx 12:33 Lab results: Urine blood 2+, protein 1+.

xx/xx/xxxx 13:05 Addendum by XXXXXX xxxxxx, PA receipt acknowledged by XXXXXX xxxxxx, RN. Per chart review, patient with a PMH of Hematuria / Elevated PSA who is follow-upped (sic) by Urology clinic last seen xx/xx/xxxx and is scheduled on xx/xx/xxxx for biopsy. Will defer to RN to contact the Veteran to inform him that his U/A continues to show blood with no infection noted. Please advise Veteran to keep his scheduled Urology follow-up who is managing his persistent hematuria.

xx/xx/xxxx 14:17 Addendum by XXXXXX xxxxxx, PA, receipt acknowledged by XXXXXX xxxxxx, PA; XXXXXX xxxxxx, MD, XXXXXX xxxxxx, MD. Called and spoke to pt about results showing positive for cancer. Will schedule f/u visit in 1-2 weeks to further discuss. Letter will also be mailed with his results. Pt completed his course of antibiotics after his biopsy. He still notes some intermittent blood in his urine but otherwise no dysuria, no frequency, no urgency, no fever, no chills. He had 1 episode of some nausea yesterday but that resolved and has not recurred. Currently he feels very well. Pre and post procedure urine cultures were negative.

xx/xx/xxxx 14:13 Urology note by XXXXXX xxxxxx, PA, Urology receipt acknowledged by XXXXXX xxxxxx, MD. Discussion with the patient during today's visit involved his diagnosis of prostate cancer and all treatment options going forward, including active surveillance, radical prostatectomy, external radiation therapy, brachytherapy (radioactive-seed implant), and others. Pt also reports he has private insurance and would like to also seek second opinion. He is undecided at this time on which treatment option he would like to pursue.

XXXXX11:35 Urology note by XXXXXXXXXX, MD, PGY4. Presents for follow-up of Gleason 3+4=7 prostate cancer. He has seen radiation oncology at XXXXXVAMC and Cancer Treatment Centers of America (CTCA) and would like to pursue high dose brachytherapy. He reports that he had an MRI and bone scan performed at CTCA, which were normal. Has had microscopic hematuria in the past. XXXXX creatinine 1.35 H. CT abdominal /pelvis with and without contrast ordered. Repeat BMP ordered as Cr is 1.3. Will have pt return to clinic in 2 months to discuss results of CT. He does not want to have cystoscopy at the moment .

XXXXXUrology Letter by XXXXXXXXXX, PA, Urology. I wanted to inform you of the results of your most recent imaging study. Abdomen and Pelvis without and with contrast CT scan (XXXXX) Impression: 1. 3 mm non-obstructing left renal calculus. There is no hydronephrosis. 2. Right renal cyst, as described above. There are sub-centimeter bilateral renal hypodense lesions, which are too small to further characterize. 3. Mild to moderate colonic diverticulosis without evidence of diverticulitis. 4. Coronary artery atherosclerosis. 5. Status post cholecystectomy. 6. Findings in keeping with sequela of prior granulomatous disease. 7. Small duodenal diverticulum. We will review in more detail at your upcoming appointment scheduled for XXXXX.

XXXXX9:21 Lab results: Creatinine 1.4 H.

XXXXX16:01 Addendum by XXXXXXXXXX, MD. Repeat serum creatinine level is within acceptable range.

XXXXX11:18 Urology note by XXXXXXXXXX, MD. presents for follow-up of Biopsy proven adenocarcinoma the prostate. Patient has opted for radiation therapy. He is negotiating with choice regarding the type of radiation. He had microscopic hematuria prior to the biopsy. CT is unremarkable except for a small renal calculus. Recommendation: Cystoscopy to complete hematuria workup Follow-up with radiation oncology Cystoscopy Orders: 1. Schedule Cystoscopy 2. Instruction Sheet for Procedure was given to patient 3. Urine C&S, HIV & Hep C Screen if > 2 months (CEA & CA 19-9 in follow-up diagnosis Bladder Cancer).

XXXXX8:57 Physician Progress note by XXXXXXXXXX, MD. Presents today for follow-up visit. Reported that he has been approved for Brachytherapy. May also have external radiation therapy. Assessment and plan: 1) Type II DM: Fasting blood sugar runs b/n (sic) 130-150. Check HGB A1C for monitoring. 2) Prostate Cancer: Follow-up with private Oncologist through choice program. 3) Osteoarthritis: stable. 4) Hematuria: follow-up with VA Urologist. 5) Hyperlipidemia: Check FLP. 6) Health maintenance: Routine lab tests ordered. I reviewed and discussed the prior lab results with the patient. Follow-up 6 months. Note: this entry was not signed by Dr. XXXXXXXXXXuntil XXXXX.

XXXXX9:21 Order by XXXXXXXXXX, MD for comprehensive metabolic panel which includes creatinine level.

XXXXX9:31 Lab results: Creatinine 2.3 H.

XXXXX15:07 Physician Urgent Care note by XXXXXXXXXX. Complains of pain. States that the Hydrocodone does not help. " I was taking Advil. That helped. They told me to stop because of my kidneys. I can swallow liquids but it hurts. I just hurt all over. I am going to see a Rheumatologist in August. I guess that is as good as I would get with the VA. Denies shortness of breath. States that he had chills last night. Denies upper respiratory symptoms exposure. Rate/Rhythm-Irreg. irregular. Assessment/plan: Chronic pain PRN pain meds as per private specialist. Activity as tolerated. Rhinitis/Sore throat. Throat culture. Loratadine and Flonase Hydrate Irregular heart rate. EKG. Skin lesion. Telederm. Return to clinic worsening or no improvement. Follow-up primary care provider as scheduled.

XXXXX11:51 Non-VA XXXXXXXXXX Hospital History and Physical by XXXXXXXXXX, MD. Sent in from Dr. XXXXXXXXXX office. Chief complaint shortness of breath, sore throat, difficulty swallowing. Assessment/Plan: upper respiratory symptoms-azithromycin, acute renal failure, acidosis-metabolic with respiratory compensation most probable cause being renal failure-tubular, lactic acidosis, metformin toxicity. Will likely require at least 2 midnights in the hospital for treatment.

XXXXX 8:35 Primary Care Telephone Encounter note by XXXXXXXXXX, RN receipt acknowledged by XXXXXXXXXX, MD. Patient states he has been in the XXXXXXXXXX hospital since XXXXX. States "my kidneys are shotdown" Relates his kidney function was 5%. He had liver and kidney biopsy done. Unknown when he will be released.

XXXXX13:22 Non-VA XXXXXXXXXX Progress note by XXXXXXXXXX, MD. History of diabetes mellitus II, hyperlipidemia, benign prostatic hypertrophy, osteoarthritis, and history of prostate cancer (recent diagnosis, followed at the VA) as well as history of nephrolithiasis 2 weeks prior to arrival who presented to the Emergency Department with complains of dyspnea, cough and sore throat with reports of )2 sats in the 60s with EMS who was admitted XXXXXwith upper respiratory symptoms, acute kidney injury, metabolic acidosis and hyperkalemia. Nephrology consulted. Renal biopsy done XXXXXamong large serology work up-results showing changes consistent with rapidly progressive glomerulonephritis and plans per Nephrology after discussed with patient and family is to start pulse dose steroids followed by cyclophosphamide therapy for treatment. Chest pain with initiation of steroids on XXXXX-EKG and troponin normal. Cytoxan started XXXXXby renal. Levemir started XXXXX for worsening blood sugars from steroids. Switch to PO prednisone planned for XXXXX by renal. Improvement in renal function daily since start of these treatments. Long acting insulin started with food results for better control of blood sugar while on steroids. Noted to have increased urine output of over 7 L in 24 hours of XXXXX-XXXXX so IV fluids started per renal on XXXXX to help avoid dehydration. Patient was continued on IV fluids due to high urine output.

XXXXX 23:12 Primary Care Telephone Encounter note by XXXXXXXXXX, MD. Patient discharged from XXXXXXXXXXXXXXXhospital.

XXXXX 13:28 Addendum by XXXXXXXXXXXXXXX, MD. Medical record received, reviewed and submitted for scanning. Health facility: XXXXXXXXXXXXXXXHospital. Admission: XXXXX through XXXXX, for management of acute kidney injury. Renal biopsy revealed rapidly progressive glomerulonephritis. Follows with private Oncologist for prostate cancer.

XXXXX11:51 Primary Care Telephone Encounter note by XXXXXXXXXX, RN. Patient brought in cyclophosphamide 50 mg cap prescription from kidney clinic and wants to pick up at the main VA pharmacy today. Patient’s next appointment: recall XXXXXXXXXX.

XXXXX 16:54 Nephrology Telephone Encounter note by XXXXXXXXXX, MD, receipt acknowledged by XXXXXXXXXX, MD. Called patient in response to email that I received at 4:40 PM today: Had upper respiratory symptoms last year took over-the-counter medications, then took Advil and Alleve. MD at VA (XXXXXXXXXX) told patient to stop taking Advil or Alleve because is bad for kidneys. Patient does not recall being told that he had kidney dysfunction. Patient continued to take Alleve or Advil. Patient came into see VA last year, was seen by someone other than primary care MD and per patient was told "nothing could do" for patient, but per patient there was no discussion of renal dysfunction. Went for private care, At outside hospital (XXXXXXXXXX) was given Toradol after labs were drawn, but before labs were known. Cr was > 10. Admitted, had renal biopsy, had rapidly progressive glomerulonephritis, pauci immune P-ANCA +, was given cyclophosphamide. At outside private MD, WBC count was low and was taken off cyclophosphamide. Reports his GFR in 20's. Sees private nephrologist XXXXXXXXXX. Reviewed consult and chart: Cr 2.32 on XXXXX. Nephrology not consulted. I asked patient if he wanted to be seen by VA renal and he said yes. I will place a nephrology consult.

XXXXX 8:22 Addendum by XXXXXXXXXX, MD. I emphasized to the Veteran yesterday during our conversation the importance of him bringing, with him to his XXXXX VA nephrology team appointment (to be scheduled), medical records from the outside care sites related to his renal dysfunction, especially the renal biopsy report.

XXXXX19:11 Addendum by XXXXXXXXXX, MD. Was diagnosed with rapidly progressive glomerulonephritis after presenting to non-VA hospital with active urine and increase creatinine at outside hospital. He also had constitutional symptoms of vasculitis. He was on Cytoxan but discontinued secondary to low WBC. He has a prescription for Imuran and transferring care over here. Renal function stable. Ordered TPMT. Follow-up 2 weeks.

XXXXX13:18 Nephrology note by XXXXXXXXXX, MD. Assessment/plan: History of rapidly progressive glomerulonephritis status post treatment now with chronic kidney disease 4. 1. History of rapidly progressive glomerulonephritis +ANCA vasculitis. Status post Cytoxan/prednisone. Off steroids. No need for pneumocystis carinii prophylaxis. On Imuran for maintenance. I am fairly sure the TPMT (sic) activity will be fine but will follow-up to make sure. If the activity is low he will be at higher risk for toxicity from Imuran. this pt had no extra renal manifestations of his vasculitis so he will probably require ~ 12-24 months of maintenance (stop date will be XXXXX- XXXXX) he should continue the Imuran 100mg q day for now. We will follow CBC to make sure he does not become too leukopenic. WBC today is 5.1 which is fine. Urinalysis is pending. Assuming the hematuria is limited this means that he is in remission. If there is a lot more hematuria we will assess for disease flare and possible reinduction. My preference would be for Rituxan given his history of significant leukopenia from Cytoxan. PR 3 from earlier this month was 45. If the hematuria is not present this is irrelevant. However, positive ANCA levels (and rising) are certainly a risk for flares and will require longer maintenance regimens. If he is deemed ultimately to be higher risk we will continue maintenance for up to 36 months. Chem also pending today. Will follow-up. 2. Anemia HGB is ok. Will follow the anemia of chronic kidney disease in clinic follow-up. 3. MBD (sic) continue Phoslo with meals. Follow-up pth (sic) and Vitamin D in future visits.

XXXXX 11:29 Addendum by XXXXXXXXXX, MD. Creatinine stable. Potassium back to normal. Albuminuria ~ 600mg. Urine RBC's at 2. Down from 98 on our previous check. It appears that his disease is in remission. We will continue Imuran per my previous note. Will continue chronic kidney disease care as indicated. Continue with follow-up XXXXX and XXXXX.

XXXXX 12:20 Nephrology Progress note by XXXXXXXXXX, MD. Hx vasculitis and biopsy proven (XXXXX) which showed Pauci-immune, necrotizing and crescentic GN who presents for follow-up. Taken off Cytoxan in March secondary to low WBC and switched to Imuran 100 mg po daily in May. Here for lab and BP check after adding losartan. Also history of prostate cancer diagnosis XXXXX, seen by urologist. Has previous wavy crampy pain , last episode 2 months ago and patient believed he passed a stone since pain went away, no hematuria, but not sure was stone. Has had similar pain about 9 times in the past, he believes were kidney stones because the pain went away. The pain was wavy and in the lower back. Did not seem to migrate. Never had hematuria. Never had a visible stone. Never had severe pain. Is in tort claim because he reports he was "blown off" by initial provider at VA, who was a NP but had a doctorate degree but told the patient was a doctor. Went to private MD to get diagnosed with glomerulonephritis.(See XXXXX nephrology telephone note).

XXXXX15:40 Nephrology Progress note by XXXXXXXXXX, MD. Here for follow-up. He is feeling well with no issues- taking Imuran no side effects. No rash, fever or chills , muscle aches and urinating well. Assessment: CKD second vasculitis GN- on Imuran. continue Imuran for now -if flare consider Rituxan. Order us of kidney. Anemia MBD within desired range. HTN well controlled DM- on insulin- controlled ? neuropathy from dm versus vasculitis Plan: return to clinic in 3 months order us of kidney renew meds no nsaids.

XXXXXClaim filed.

CPP Evaluation of Care

Restatement of Allegation:

Failure to diagnose and refer to nephrologist forced Veteran to seek out private care where he was treated for kidney failure due to Stage 4 Chronic Kidney Disease and renal cancer.

Was the Standard of Care Provided?

No.

If the standard of care was not provided, then is this attributable to the actions of a licensed practitioner?

Yes, by XXXXXXXXXX, MD-Primary Care.

• Is the identified practitioner a trainee or resident? If so, provide the name of supervising physician.

No.

• Have all identified practitioners (including physician supervisors when indicated) been given an opportunity to provide a statement?

Yes.

• Are there extenuating circumstances to be considered?

No.

• Is an additional review of care by another specialty recommended?

No.

Rationale for the Determination:

At the time of the allegation this was a 59-year-old Caucasian Veteran with past medical history of diabetes mellitus, hypertension, elevated prostate specific antigen, degenerative arthritis, obesity, hyperlipidemia, low back pain, and chronic fatigue syndrome.

On XXXXXthe Veteran was seen in the primary care clinic in the XXXXXXXXXX VAMC located in XXXXXXXXXXby XXXXXXXXXX, MD who noted: “Presents for follow-up visit. No major health issues reported during this encounter. Assessment and plan: Type II diabetes mellitus: HGB A1C 6.9 on XXXXX; at goal. Osteoarthritis: Stable. Hyperlipidemia: LDL 92 on XXXXX. On statin regimen. Hematuria / Elevated PSA: Scheduled on XXXXX for biopsy; patient is aware. Check UA/UC. 6) Obesity: Declined dietary counseling. 7) Health maintenance: Will bring colonoscopy report. I reviewed and discussed the XXXXX lab results with the patient. Follow-up 6 months.”

On XXXXX, lab results revealed: Creatinine 1.4 H. (ULN 1.2). GFR 54 (NL>60). Urine blood: 3+, protein 2+, RFC/HPF 14.

On XXXXX, lab results revealed: Urine blood 2+, protein 1+.

On XXXXX, XXXXXXXXXXXXXXX, PA receipt acknowledged by XXXXXXXXXX, RN noted: “Per chart review, patient with a past medical history of Hematuria / Elevated PSA who is follow-upped (sic)by Urology clinic last seen XXXXXand is scheduled on XXXXXfor biopsy. Will defer to RN to contact the Veteran to inform him that his U/A continues to show blood with no infection noted. Please advise Veteran to keep his scheduled Urology follow-up who is managing his persistent hematuria.”

Soon after in XXXXX XXXXX, the Veteran is diagnosed with prostate cancer and is followed by urology. In XXXXX XXXXX urology notes the creatinine at 1.3 from XXXXX and a XXXXX CT of the abdomen and pelvis without and with contrast CT scan showing: “Impression: 1. 3 mm non-obstructing left renal calculus. There is no hydronephrosis. Right renal cyst, as described above. There are sub-centimeter bilateral renal hypodense lesions, which are too small to further characterize.”

On XXXXX, XXXXXXXXXX, MD noted: “Repeat serum creatinine level is within acceptable range.” The creatinine was posted as 1.4 on that day.

On XXXXX, Donald Finnerty, MD, Urology noted: “He had microscopic hematuria prior to the biopsy. CT is unremarkable except for a small renal calculus. Recommendation: Cystoscopy to complete hematuria workup Cystoscopy Orders: 1. Schedule Cystoscopy 2. Instruction Sheet for Procedure was given to patient 3. Urine C&S, HIV & Hep C Screen if > 2 months (CEA & CA 19-9 in follow-up diagnosis Bladder Cancer).”

On XXXXX at 8:57, XXXXXXXXXX noted: “Presents today for follow-up visit. Reported that he has been approved for Brachytherapy. May also have external radiation therapy. Assessment and plan: 1) Type II DM: Fasting blood sugar runs b/n (sic) 130-150. Check HGB A1C for monitoring. 2) Prostate Cancer: Follow-up with private Oncologist through choice program. 3) Osteoarthritis: stable. 4) Hematuria: follow-up with VA Urologist. 5) Hyperlipidemia: Check FLP. 6) Health maintenance: Routine lab tests ordered. I reviewed and discussed the prior lab results with the patient. Follow-up 6 months.” This note was not signed until XXXXX.

On XXXXXa creatinine ordered by XXXXXXXXXXat 09:21 was reported as 2.3 at 9:31 that same day.

On XXXXX, XXXXXXXXXX, NP in Urgent Care noted: “Complains of pain. States that the Hydrocodone does not help. ‘I was taking Advil. That helped. They told me to stop because of my kidneys. I can swallow liquids but it hurts. I just hurt all over. I am going to see a Rheumatologist in August. I guess that is as good as I would get with the VA.’ Denies shortness of breath. States that he had chills last night. Denies upper respiratory symptoms exposure. Rate/Rhythm-Irreg. irregular. Assessment/plan: Chronic pain PRN pain meds as per private specialist. Activity as tolerated. Rhinitis/Sore throat. Throat culture. Loratadine and Flonase Hydrate Irregular heart rate. EKG. Skin lesion. Telederm. Return to clinic worsening or no improvement. Follow-up primary care provider as scheduled.”

On XXXXX, a telephone encounter by XXXXXXXXXX, RN receipt acknowledged by XXXXXXXXXX noted: “Patient states he has been in the XXXXXXXXXXXXXXX hospital since XXXXX. States ‘my kidneys are shotdown’ Relates his kidney function was 5%. He had liver and kidney biopsy done. Unknown when he will be released.”

The stated chief complaint at XXXXXXXXXX admission on XXXXX was shortness of breath, sore throat and difficulty swallowing.

On XXXXX, XXXXX noted: “Medical record received, reviewed and submitted for scanning. Health facility: XXXXXXXXXX Hospital. Admission: XXXXX through XXXXX, for management of acute kidney injury. Renal biopsy revealed rapidly progressive glomerulonephritis. Follows with private Oncologist for prostate cancer.”

Per the XXXXX primary care note, the Veteran was to for a follow-up with primary care in six months which would have been in November XXXXX but that did not occur. He did refill an outside script for cyclophosphamide at the VA December XXXXX.

The next encounter with the VA is April XXXXX.

On XXXXX, a nephrology telephone encounter by XXXXXXXXXX, MD, receipt acknowledged by XXXXXXXXXX, MD noted: “Called patient in response to email that I received at 4:40 PM today: Had upper respiratory symptoms last year took over-the-counter medications, then took Advil and Alleve. MD at VA (XXXXXXXXXX) told patient to stop taking Advil or Alleve because is bad for kidneys. Patient does not recall being told that he had kidney dysfunction. Patient continued to take Alleve or Advil. Patient came into see VA last year, was seen by someone other than primary care MD and per patient was told "nothing could do" for patient, but per patient there was no discussion of renal dysfunction. Went for private care, At outside hospital XXXXXXXXXX) was given Toradol after labs were drawn, but before labs were known. Cr was > 10. Admitted, had renal biopsy, had rapidly progressive glomerulonephritis, pauci immune P-ANCA +, was given cyclophosphamide. Sees private nephrologist Dr. XXXXXXXXXX. Reviewed consult and chart: Cr 2.32 on XXXXX. Nephrology not consulted. I asked patient if he wanted to be seen by VA renal and he said yes. I will place a nephrology consult.”

On XXXXX, Dr. XXXXXXXXXX noted: History of vasculitis and biopsy proven (XXXXX) which showed Pauci-immune, necrotizing and crescentic GN who presents for follow-up. Is in tort claim because he reports he was "blown off" by initial provider at VA, who was a NP but had a doctorate degree but told the patient was a doctor. Went to private MD to get diagnosed with glomerulonephritis.(See XXXXX nephrology telephone note).”

The allegation is for failure to diagnose and refer to a nephrologist which forced the Veteran to seek out private care where he was treated for kidney failure and renal cancer.

The central issue in this case is the significant change in the Veteran’s renal function from his baseline evidenced by a creatinine level of 2.3 on XXXXX, that was not addressed by XXXXXXXXXX who ordered it. Later, on XXXXX, the Veteran would go on to a diagnosis of rapidly progressive glomerulonephritis and was treated at a non-VA facility.

In his statement, XXXXXXXXXX focuses on the central issue in this case by pointing out in great detail how he was getting ready to travel for an extended period of one month just after the encounter with the Veteran on XXXXX. XXXXXXXXXX states he had a full schedule the next day when the lab was posted and then was packing for the trip and missed it. XXXXXXXXXX further ponders if a referral to nephrology at the time the lab was posted would have prevented the hospitalization a month later.

XXXXXXXXXX, NP was also asked to provide a statement and in it she reports that she could not have anticipated a rare condition like rapidly progressive glomerulonephritis and certainly did nothing to cause or worsen the issue.

This reviewer’s assessment is to determine if the standards of appropriate medical care were maintained irrespective of the possibility that a lack of appropriate care does not affect the outcome.

In this case, XXXXXXXXXX had an obligation to address the XXXXX abnormal creatinine in an expeditious fashion. He was not away and was at the VA at the time the lab was posted per his own post factum statement. Therefore, he had an opportunity to review and respond to the lab and having a full schedule and having to pack for the trip are not acceptable excuses for failing to act on that significantly abnormal test.

Though not germane to the issue of standard of care in this case, time was of the essence here as the development of rapidly progressive glomerulonephritis can result in progressive and significant loss of renal function over a relatively short period of days or weeks1,2. The fact that this disease process is relatively rare with often an insidious onset,1,2 is immaterial here as XXXXXXXXXX had lab evidence of significantly worsening renal failure and did not act on it.

These facts however, would exonerate NP XXXXXXXXXX as this reviewer agrees with her statement that there was no way she could have anticipated that condition. The only issue with NP XXXXXXXXXX XXXXX encounter with the Veteran was an opportunity to have seen the XXXXX abnormal creatinine result and to have checked to see if it was addressed, but given the reason for the encounter was pain, one would not have definitively expected NP XXXXX to have reviewed recent labs based on the Veteran’s presenting complaints.

In summary, in my professional opinion, I feel that XXXXX XXXXX, NP, met the standard of care for this Veteran. However, I feel that by XXXXXXXXXX, MD, Primary Care, did not meet the standard of care for this Veteran.

Pertinent Citations:

1. Couser WG. Rapidly progressive glomerulonephritis: classification, pathogenetic mechanisms, and therapy. Am J Kidney Dis. 1988;11(6):449-464. doi: 10.1016/s0272-6386(88)80079-9.

2. Moroni G, Ponticelli C. Rapidly progressive crescentic glomerulonephritis: Early treatment is a must. Autoimmun Rev. 2014; 13(7):723-729. doi: 10.1016/j.autrev. 2014.02.007.