Failure to review radiology report

Presentation and physician action

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A 63-year-old woman came to her internal medicine (IM) physician reporting lower back and flank pain. The IM physician found that the patient had tenderness in her left lower quadrant. He was concerned about kidney stones, so he ordered a stat CT scan of the patient’s abdomen.

The CT was completed that day and read by a radiologist. The radiologist called the IM physician and reported that there were no kidney stones, but he felt the patient had a possible epiploic appendagitis.

That evening, the IM physician called the patient at home. He told her that there were no kidney stones, and recommended that she take anti-inflammatories.

When the radiology report came to the IM physician’s office, he initialed the report without reading it since he had received an oral report from the radiologist.

Under the “Impression” section, the radiologist’s report said: 


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“1. Sigmoid colon diverticulosis, without evidence of diverticulitis.
 2. Ring-like area stranding posterior to the sigmoid colon on the left posterior pelvis, nonspecific although possibly due to epiploic appendagitis.
 3. 8 mm non-calcified pulmonary nodule in the left lower lobe, incompletely imaged. This is not appreciated on prior CTs of the abdomen. Recommended follow-up CT chest for further evaluation if clinically warranted.”


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Thirteen months later, the patient went to the emergency department (ED) of a local hospital. She reported numbness and tingling in her left hand and face, and some imbalance in her legs. These symptoms began the day before she went to the ED, but she had been experiencing memory difficulties and irritability for the past six months.

A CT scan of the head showed a 2.7 cm mass in the right front parietal area of the brain. Subsequent imaging of the abdomen revealed a 3x3x2.7 cm lobular mass in the patient’s left lung. According to the pathology report, the tumor in the patient’s brain was metastatic carcinoma resulting from a primary lung carcinoma.

The patient began radiation therapy, but died five months later.

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Allegations

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A lawsuit was filed against the IM physician, alleging:

• failure to order testing to further evaluate the lung nodule;
• failure to refer the patient to a specialist for evaluation of the lung nodule; and
• failure to timely diagnose and treat the patient’s cancer.

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Legal implications

Physicians who reviewed this case for the defense criticized the IM physician for not reviewing the radiology report. Many of these consultants stated that it was their practice to review all reports that come in, whether or not they had discussed the findings with the radiologist. The IM physician initialed the report, which is usually done to indicate that the physician has read the report.

The IM physician stated that the radiologist told him the results of the study as far as the flank pain was concerned. The IM physician then called the patient and reported these findings. When he received the report, he initialed it to be put in the file because he had already spoken to the radiologist and advised the patient. He was adamant that he was not told about the lung nodule during the phone call.

Regarding causation, the plaintiff’s oncology expert testified that he did not believe there were brain metastases at the time of the CT scan. Therefore, the patient had a greater than 50 percent survival rate if her cancer had been diagnosed and treated timely.

The defense oncology expert testified that the patient had a large-cell neuroendocrine cancer of the lung. This is a rapidly growing, aggressive cancer that — even if diagnosed at stage 1 and resected — prognosis for surviving this type of cancer was less than 50 percent.

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Disposition

This case was settled on behalf of the internal medicine physician.

‍More on documentation errors.

Risk management for adult primary care physicians.

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