Legal Case Woman’s Health

Nivi was seen by a physician covering for her regular primary care physician. She was noted to have a mass in her right breast.

The covering doctor documented the presence of a mass in the upper outer quadrant of the right breast and she was referred for a mammogram and breast ultrasound. The mammogram was performed the following day and indicated there were fibroglandular densities visible within the breasts, with no specific evidence of malignancy.

Due to the presence of a palpable abnormality, a right breast ultrasound was performed and the prior mammogram films were obtained for comparison.

The ultrasound performed that day indicated that this study failed to demonstrate a mass or cyst. Clinical follow-up of the palpable thickening within the right breast was recommended.

An addendum to the mammogram report indicated that the prior mammogram from December 1992, had been reviewed, with the overall density of the breasts having diminished since the 1992 study with no significant change noted. The reports were sent to the covering doctor.

The record contains no indication that the covering doctor recommended any further follow up for the breast mass.

Nivi did not return to her physician for about four years, in February 2006, at which time she was seen by the Nurse Practitioner. The Nurse Practitioner noted that Nivi’s right nipple was inverted and she had a palpable breast density at 2:00 o’clock. The NP noted that this breast density had been worked up four years earlier with nothing noted. Nivi reported the mass had become larger over time.

The NP described the mass as diffuse, with no margins and was slightly tender.

She recommended a diagnostic mammogram with follow-up in four weeks.

A diagnostic mammogram was performed that day, which indicated that there were findings which were suspicious for malignancy.

A right breast ultrasound was also performed for further evaluation the following day, and failed to demonstrate any abnormality. The report indicated that clinical correlation was advised.

Nivi was seen again by the Nurse Practitioner in March 2006.

The records indicated that the diagnostic mammogram and ultrasound showed no changes from the previous monitoring. There was no indication in the records that the Nurse Practitioner performed an actual physical examination of the breast during this visit. There is also no indication that the Nurse Practitioner discussed the abnormal mammogram report or the presence of the persistent breast mass and nipple inversion with the supervising physician. There is also no indication that the Nurse Practitioner referred the plaintiff to a surgeon for further evaluation at that time.

Following this visit, the finding of a “benign breast mass” was entered into the patient’s past medical history.

Over the next few months, the patient was seen by the Nurse Practitioner and her supervising physician, the Nivi’s primary care, on several occasions for evaluation of blood pressure and cholesterol. There is no indication of any further evaluation of the right breast mass.

Nivi developed a severe and persistent headache. She was seen by another physician covering for her PCP, who diagnosed a sinus infection. Several rounds of antibiotics did not relieve the symptoms and she developed a new symptom of a drooping left eye but did not report this change to her provider.

Nivi was seen again by her PCP in January 2007, at which time cervical lymphadenopathy on the right side and the drooping left eyelid were noted.

A brain MRI was performed later in January 2007, which revealed several areas of abnormality in the brain.

A breast MRI was also ordered by the doctor and performed in early February 2007, which noted significant axillary adenopathy bilaterally. The right breast appeared contracted with nipple retraction with diffuse enhancement of the right breast parenchyma, primarily in the upper central and outer quadrants.

The left breast also showed a large area of abnormal enhancement in the upper central and medial quadrant as well as a more discrete enhancing mass at 6:00 o’clock.

Biopsies of the abnormalities in both breasts and axillary lymph nodes were recommended and Nivi was referred to a breast surgeon.

Nivi was then referred to another physician at the brain tumor center for evaluation of the brain masses.