| MEDICAL RECORD SUMMARY |
re:
Professional Negligence
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Re: Medical records entries dated from 11.28.98 to 3.28.01, including date of discovery of right breast lump, diagnosed as Infiltrating ductal carcinoma, and surgical removal by modified radical mastectomy.
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TIMELINE
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It appears
that the patient discovered the right breast lump when she was seven
months pregnant and didn't report it until 06.21.99, one week before
her due date. |
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06.21.99
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Dr.
Goodfellow examined the right breast lump, but did no immediate lab
work, sonogram, mammogram or other testing regarding it. Patient was encouraged to breast feed
even though the lump was present. |
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06.26.99 |
Dr. Taylor
delivered baby and the lump was examined and patient was scheduled
for an appointment with Surgery for 07.02.99.
There is no further reference made to the appointment scheduled for
07. 02. 99. |
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07.01.99 |
Patient
no show. Patient's appointment was rescheduled for 07.15.99 and again
rescheduled for 07.19.99. |
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07.19.99 |
Patient was
treated for lower back pain which was diagnosed as being caused by
epidural/delivery prescribed isometric exercise and Motrin for pain advised
to both sit and stand when breast feeding and referred to physical therapy. Neither
a biopsy nor a mammogram nor other exam or testing of the lump was done at
that time. |
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08.17.99 |
Patient
didn’t show up for her appointment, was still breast feeding, but
having difficulty, and right breast was engorged. |
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08.25.99 |
Patient
came to her appointment. She complained regarding lower back pain and
the lump hindering breast feeding since 07.30.99. was treated for back
pain and prescribed Advil. |
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09.27.99 |
Sonogram
=mass 2.4 x 2.6 cm, indistinct. Patient phoned and requested the results
of the ultrasound done 09.27.99. Patient was advised the ultrasound
of the right breast showed that there was a mass, size 2.4 x 2.6 cm.
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10.15.99 to
11.9.99 |
Patient was
sent to physical therapy for her back pain and was given a medical excuse
from work. There was no record showing that she received further
examination testing or treatment for the right breast lump during that time. |
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11.10.99 |
Sonogram
= infiltrating ductal cancer B-R score 8/9, mass 2.3 x 3 x 4.3 cm, located
about 10 - 12 o'clock, speculated margins with increase in size since
September 1999. |
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11.11.99 |
Surgical
Pathology Consultation Report (Ku & Kunno) Final Diagnosis: Infiltrating
ductal carcinoma, needle biopsy, right breast, and upper outer quadrant.
Comment: The infiltrating duct carcinoma reveals 3/3 tubule formation, 3/3
cytologic atypia, and 2/3 mitotic activity for a score of 8/8 or Scarf Bloom
Richardson grade III. Dr. Ku's phone mail was notified. Specimen: R.
breast needle core BX UOQf Clinical
Data: 2.3 x 3.0 x 4.3 cm solid suspicious mass, right breast at 10-12
o'clock. Gross
Description: Four needle core biopsies ranging in length from 0.5 to 1.2 cm.
All. DAT/1mr |
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11.12.99 |
Dr. Ku did a
breast exam; sketch indicated the location of the mass. He is opinion was that patient was a
lactating woman with infiltrating breast cancer. Patient complained to Dr, Ku
about the continuing pain in her lower back. She had difficulty sitting
because of the pain. She was advised to call if she wanted a disability
certificate. |
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11.16.99 |
Patient
was given a medical excuse from work since she would be unable to perform
her duties until 02.01.00 because she had cancer and was to undergo
surgery and chemotherapy. |
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11.19.99 |
Request For
Operation, Anesthesia, Transfusion And Medical Services (Ku) Modified radical
mastectomy to remove the right breast and lymph nodes. |
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11.19.99 |
Radiology
Report: Patient had
minimal lower thoracic levoscoliosis, a sideways curvature of the spine, and
osteoporosis, excessive skeletal fragility resulting in bones that break
easily. The rest of the lungs and chest cavity was normal. |
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11.24.99 |
A biopsy of
right breast tissue was performed at time of surgery shortly before the
mastectomy. Tests of the specimen confirmed that |
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she had cancer
of the right breast and surrounding axillary lymph nodes. The right breast
and lymph nodes were removed. Surgery was uneventful. When patient was
recovering, she was encouraged to breast feed using the remaining breast. |
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11.24.99 to
5.26.00 |
After surgery
she was given chemotherapy until 05.26.00, when she was released from
treatment. She was evaluated 07.16.00 and considered to have no further
cancer, mastectomy had healed well, and she had full mobility of the
right arm. Her left breast was also free of lumps. |
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