A 52-year-old mildly obese woman with a history of hypertension and fibrocystic breast changes was seen by her PCP for a physical exam. The patient had had yearly screening mammograms, which were negative, and she had no family history of breast cancer. The physician noted in the chart “multiple nodularity” of both breasts, but did not indicate the nodular findings were significant. A (previously-scheduled) screening mammogram conducted the following month showed no changes in the patient’s breasts.
One year later, the patient was seen again by her PCP and diagnosed with hidradenitis (a chronic, pus-producing disease process caused by obstruction of the hair follicles and secondary infection and inflammation of certain sweat glands). The PCP did not document his findings in the chart. The patient was treated with antibiotics, and returned 10 days later, when the PCP noted “hidradenitis improved.” No breast exam was documented at either visit. The patient already had an appointment for a prescheduled screening mammogram one month later.
The mammogram requisition form, under clinical history, noted “large increase left breast tissue 12:00 as opposed to right,” and the box next to the question Have you or your physician felt a lump in your breast? was checked YES (on the patient’s previous screening mammograms, this question was checked NO.) The mammogram results were reported as normal. The physician did not initial the hard copy to indicate he had reviewed the screening mammogram report, nor did he mention the findings in the medical record. He did not discuss with the patient the increased breast tissue and presence of a lump that were mentioned on the requisition form and the hard copy of the report.
Seven months later, the patient was again diagnosed with hidradenitis, which resolved with antibiotics. On exam, the PCP noted a large node on the left axilla. When the nodes persisted during two re-examinations over the next four weeks, the patient was sent for a diagnostic mammogram followed by a biopsy. She was diagnosed with inflammatory breast cancer and underwent aggressive treatment. She died four years later at age 56.