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Patient Record and Medical Chart Review
IDFAX provides a review of the medical record and medical chart of patients suffering from an infectious disease.
IDFAX provides an Expert Medical Opinion of the patient's medical record or chart. The IDFAX Expert Medical Opinion includes:
- answers to specific questions raised by legal counsel, detailed responses based on the patient's chart or record, published medical references and Dr. Rubinstien's expertise
- assistance in pre-trial preparation, background medical information
- glossary of medical terms used in the Medical Opinion, explanantion of medical terms given in lay language
- relevant references from the medical literature
IDFAX does not provide court testimonies.
Recent Medical Charts IDFAX has reviewed include:
A patient had died of AIDS which he had contracted from a blood transfusion. The family held the hospital responsible. Was the hospital negligent?
Following review of the medical chart the following conclusions were reached:
- Three possible exposure risks to HIV infection were identified.
- Infection from a blood transfusion was the most likely route of infection.
- The transfusion was administered prior to the development of methods of HIV testing and screening of blood units.
Consequently, the hospital could not be accused of negligence.
A patient developed loss of balance and decreased hearing as a complication of antibiotic therapy administered for a life-threatening illness. The patient held the physicians responsible. Were the physicians negligent?
Following review of the medical chart the following conclusions were reached:
- The antibiotics adminstered were inappropriate for the patient's specific illness.
- The patient received inappropriate doses of the antibiotics.
- The antibiotics administered were not in accordance with current recommendations.
- Monitoring of antibiotic serum levels was inadequate.
Consequently, the physicians could be accused of negligence.
A patient in an outlying small-town hospital underwent multiple surgeries and possible loss of the genitals due to necrotizing fasciitis of the groin and the genitals as a complication of an appendectomy. The patient held the physicians responsible. Were the physicians negligent?
Following review of the medical chart the following conclusions were reached:
- There was a delay in the diagnosis of nerotizing fasciitis.
- The delay in diagnosis led to a delay in implementing the appropriate treatment.
- Once the diagnosis of necrotizing fasciitis was established, the appropriate treatment was implemented.
- The physicians were very attentive to the patient's medical condition. However, lack of experience of physicians in an outlying small-town hospital was the most likely reason for the delay in recognizing the development of necrotizing fasciitis.
Consequently, the physicians could not be accused of negligence.
A physician estimated a patient with HIV infection to have AIDS and to have less than 2 years to live. 6 years later the patient is still alive. The Insurance company is contesting the physician's estimate.
Following review of the medical chart the following conclusions were reached:
- The information in the medical chart does not support the diagnosis of AIDS.
- The information in the medial chart suggests that the HIV infection was under control.
Consequently, the physician's estimate was incorrect.
Following trauma, a patient suffered recurrent swelling of the knee due to recurrent fluid collection. In spite of multiple drainage procedures and operations on his knee, he continued to suffer from recurrent swelling and discomfort. After several procedures, the surgeon initiated antibiotic therapy for a suspectd infection in the knee, even though cultures of multiple knee fluid specimens never grew an organism. After several weeks of drainage procedures and empiric antibiotic therapy, the knee finally healed. The patient is considering suing the surgeon for negligence.
Following review of the medical chart the following conclusions were reached:
- The information in the medial chart suggests that the surgeon acted appropriately and according to the standard of care.
- Empiric antibiotic therapy was initiated appropriately.
- Ultimately, the patient's knee healed with no residual damage.
Consequently, the patient decided not to sue the surgeon.
This service is provided by Eytan M. Rubinstien, MD, an Infectious Diseases specialist, Director of IDFAX. To avoid conflict of interest, IDFAX will not review medical charts of patients treated by institutions Eytan Rubinstien, MD is affiliated with. Please review the resume.
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