Allegation
The plaintiff alleged that the failure of the defendant internal medicine physician to follow up on a CT study resulted in undiagnosed lung cancer and death of the patient
Case Details
The patient, a 34 YOM (6’3”, 245 lb), was referred to the defendant internal medicine (IM) physician by his PCP for findings of night sweats, cervical and inguinal adenopathy, and bi-cytopenia. Based on CT and biopsy results, the insured physician diagnosed stage IV/B non-Hodgkin’s lymphoma. The patient was informed that while his disease was not curable, it was treatable and could go into remission with adequate chemotherapy.
The patient underwent chemotherapy. The following year, he was determined to have grade I to II alveolitis of the lungs, which was suspicious for recurrent lymphoma. The condition was treated successfully with chemotherapy and radiation.
Sixteen years later, the defendant IM physician saw the patient; he noted the patient was stable with normal labs and exams for the last two years. The physician recommended yearly CT scans of the chest, abdomen, and pelvis. The patient was to return in six months.
Over the next three years, the patient returned at six-month intervals without incident. A co-defendant radiologist read two of the patient’s CTs during this time. The patient remained asymptomatic and blood tests did not show a recurrence of cancer. During the final visit of this three-year timeframe, the defendant IM physician ordered labs and CT of the neck, chest, abdomen, and pelvis.
The patient had the CT within a month. Another radiologist read the film, which revealed a right lung nodule. The report was scanned into the defendant IM physician’s chart, and the practice confirmed it was received. While the defendant IM physician typically wrote his initials on CT reports upon receipt, his initials were absent on this report. Based upon this absence, the physician could not state whether or not he actually reviewed the report. No action had been taken based on the report, which identified a change from the previous exam and an increase in the size of the right lower lobe nodule that now measured about 8-9mm. Additionally, the radiologist had noted neoplastic etiology needed to be ruled out and suggested a PET scan.
The patient returned twice to the defendant IM physician over the next 12 months. The first visit concluded with the patient remaining asymptomatic and showing no signs of recurrence. The defendant IM physician authored a report to the patient’s PCP stating the patient had a scan six months ago and was essentially normal. The defendant IM physician also noted the patient’s tumor markers were normal, and that he was asymptomatic, concluding, “do not think it represents any relapse.” A fellow examined the patient on the second visit. The patient was again asymptomatic and labs were unremarkable. The defendant IM physician concurred with the fellow’s exam and elected not to set up any scans. The patient was instructed to return in six months.
Before the six-month follow-up, the patient moved and began treatment with a new physician. The patient presented to this physician seven times within a seven-week period with an array of medical concerns ranging from bilateral elbow pain to coughing up blood.
Three days after last seeing his new physician, the patient presented to a local hospital with complaints of confusion. A CT of the brain noted multiple bilateral hyper-attenuating gray-white junction masses associated with white matter edema. A chest x-ray noted a 5 cm right lower lung mass with right hilar lymph node enlargement. The MRI findings were consistent with multiple hemorrhagic metastases with associated vasogenic edema within the left parietal and occipital lobes, and within the right front, parietal, occipital, and temporal lobes. A CT of the abdomen demonstrated shotty multi-focal retroperitoneal, periaortic, and mesenteric lymph nodes. A CT-guided aspiration of the right lung mass was completed. The patient was diagnosed with non-small cell lung cancer with metastatic disease in the bones and brain.
The patient was discharged from the hospital four days later. He underwent treatment for cancer, but passed away three months later.
Expert Testimony
The plaintiff experts stated the defendant IM physician failed to meet the standard of care by not following up on the CT study, and referring the patient to a surgeon for nodule biopsy or resection. This failure to follow up resulted in a 16-month delay in diagnosis. Plaintiff experts were also expected to testify that had the patient been referred to a surgeon, the nodule would have been removed before it metastasized, giving the patient a 95% chance of full recovery. The plaintiff’s radiology expert agreed the co-defendant radiologist breached the standard of care by failing to report a potentially suspicious nodule on two separate CT studies approximately four months apart.
The defense experts were critical of the lack of an appropriate follow-up to the CT results.
Resolution
The case was eventually settled.
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