Persistent breast lumps, but no biopsy
ABOUT 3 YEARS AFTER GIVING BIRTH, a 38-year-old woman, who was still breastfeeding, went to her primary care physician complaining of pain, a dime-sized lump in her breast, and discharge from the nipple. The patient’s 2-year-old breast implants limited examination by the nurse practitioner (NP) who saw her. Galactorrhea was diagnosed and the woman was told to stop breastfeeding, apply ice packs, and come back in 2 weeks.
When the patient returned, her only remaining complaint was the lump, which the primary care physician attributed to mastitis. At a routine check-up 5 months later, the patient continued to complain of breast lumps. No breast exam was done, but the woman was referred to a gynecologist. An appointment for a breast ultrasound was scheduled for later in the month, but the patient said she didn’t receive notification of the date.
Metastatic breast cancer was subsequently diagnosed, and the woman died about 3 years later.
PLAINTIFF’S CLAIM The NP and primary care physician should have recommended a biopsy sooner.
THE DEFENSE The care given was proper; an earlier diagnosis wouldn’t have changed the outcome.
VERDICT $750,000 Massachusetts settlement.
COMMENT Failure to recommend biopsy of breast lumps is a leading cause of malpractice cases against family physicians. All persistent breast lumps require referral for biopsy— regardless of the patient’s age.
A red flag that was ignored for too long
A MAN IN HIS EARLY 30S consulted an orthopedist for mid-back pain. The doctor took radiographs of the man’s lower back and reported that he saw nothing amiss. When the man returned 3 months later complaining of the same kind of pain, the orthopedist examined him, prescribed a muscle relaxant, and sent him for physical therapy. The physician did not take any radiographs.
Four months later, the patient came back with pain in his mid-back and ribs. The orthopedist ordered radiographs of the ribs, which were read as normal.
After 18 months, the patient consulted another orthopedist, who ordered a magnetic resonance imaging scan and diagnosed a spinal plasmacytoma at levels T9 to T11. The tumor had destroyed some vertebrae and was compressing the spinal cord.
The patient underwent surgery to remove the tumor and insert screws from T6 to L2 to stabilize the spine. He wore a brace around his torso for months and had a bone marrow transplant. The patient couldn’t return to work.
PLAINTIFF’S CLAIM The tumor was clearly visible on the radiographs taken at the patient’s third visit to the first orthopedist; thoracic spine radiographs should have been taken at the previous 2 visits.
THE DEFENSE No information about the defense is available.
VERDICT $875,000 New Jersey settlement.
COMMENT Current guidelines recommend a red flags approach to imaging. This patient had a red flag—unremitting pain. When back pain persists unabated, it’s time for a thorough evaluation.