This month we look at a case where both the patient and the physician failed to follow up. It highlights the need for medical practices to have a process in place to both remind a patient to complete a test, and to remind the physician to review the results.
The patient, Mr C, was a 60-year old man with a 40-year smoking history, chronic obstructive pulmonary disease, sleep apnea, chronic bronchitis, emphysema, and obesity. He was seen in the emergency department of his local hospital for respiratory issues. A chest x-ray taken at the hospital noted a “possible 1 cm pulmonary nodule” near the patient’s left 5th rib, which had not appeared in an x-ray taken 7 months before. The radiologist recommended a left rib series, which was not done because the patient, tired of sitting around the ED, checked himself out against medical advice. The radiologist faxed the report to Mr. C’s internal medicine physician, Dr G.
Dr G sighed when he saw that the patient had checked out against medical advice, but he wasn’t surprised. The patient had a history of not following advice, starting with Dr G’s most basic advice, which he had been giving the patient since he began treating him 7 years earlier – stop smoking and lose some weight.
Before he walked into the exam room to see his next patient, Dr G instructed his nurse to call Mr C and inform him about the abnormal results of his chest x-ray and ask him to come to the practice in the near future. The call, however, was not documented in the patient’s record, and the practice did not schedule an appointment for the patient.
Two months later, the patient again went to the emergency department and was hospitalized after a serious episode of respiratory distress. The chest x-ray taken at this visit showed a node over the left 5th rib measuring 2.7 cm. The chest x-ray noted Dr G as the ordering physician, and the report was filed in the patient’s medical record in the physician’s office, but Dr G never saw this report.
The following month the patient came to the physician’s office and was diagnosed with bronchitis and treated by Dr G.
Two months later, the patient was admitted to the hospital again, this time with a differential diagnosis of pneumonia or empyema. A chest x-ray noted a mass measuring 5 cm in diameter, but a repeat film 2 days later noted that the nodule was obscured by pleural effusion. Over the next week, the pleural effusion was drained, and the patient was slightly improved, but still having issues. A month later, Dr G ordered another chest x-ray to rule out pneumonia. The radiologist recommended a CT scan, which took place a week later. The CT scan revealed a 4.5 x 3 cm mass. A biopsy indicated squamous non-small cell lung cancer, with a poor prognosis.