49yo Male, smoker with early COPD.
03/13/2023
• Presented to urgent care with chest pain; urgent care concerned about collapsed lung re: “rib pain”.
• Referred to ER (Santa Rosa Medical Center); CT Chest result: “1. Severe emphysematous change o: the right upper lobe with large bullous change into the apex. This is mimicking pneumothorax rather than contained pneumothorax a pocket of air. There is scarring and calcified granuloma into the right midlung. 2. Mild to moderate emphysematous change on the left. Old granulomatous disease sequela.” IP diagnosed with COPD/emphysema, large bullous lesion, instructed to immediately follow up with pulmonology.
04/06/2023
• First pulmonology visit with at Santa Rosa Medical Group
• Confirmed COPD; MD ordered a breathing test (PFT); no other immediate treatment or other imaging ordered.
05/08/2023
• PFT performed:
o Moderate obstructive defect (FEV1 61%, FEV1/FVC 57%)
o Severe small airway involvement (FEF25–75% at 18%)
o DLCO at 62% → impaired gas exchange
• No documented follow-up scheduled despite high-risk findings and known giant bullous emphysema
• Patient told "breathing looked great"; no inhalers Rx, case effectively closed. No follow up instructions, no other treatment or diagnostics.
05/2023 – 09/2024
• No pulmonology follow-up, imaging surveillance via pulmonology. IP states reached out multiple times but was "ghosted".
• Saw Primary in 9/2024 for routine visit, was given inhalers and noted: “Notes: Pt had a CT at Santa Rosa Medical Center in March, 2023 that showed severe emphysematous change, mainly in the RUL. I read the report on his wife's phone. Will request report from SRMC to scan into his chart. He saw pulmonology, after his ER visit to SRMC last year. Will request records. Will Rx Trelegy for maintenance, give samples, and order it for him on the PAP. Will Rx albuterol HFA for rescue. F/U in 3 months and prn.”
• Primary F/U again 12/2024 States “improved on Trelegy” and “Ordered screening labs. We didn't receive his pulmonology records, so will request these again. Will plan to see him back in 8 months. RTC prn.
02/08/2025
• Developed facial/neck swelling, jugular vein distention
• Taken to ER → CT showed large lung mass compressing superior vena cava (SVC)
02/10/2025
• Lung biopsy performed → Diagnosed with poorly differentiated carcinoma
• Likely non-small cell lung cancer, origin presumed pulmonary
• Mass compressing SVC by 60%, requiring angioplasty and stent
02/25/2025
• Second biopsy (lung and bone) → Confirmed malignancy; likely metastatic with bone involvement
• First biopsy sample had extensive necrosis, limiting classification
Currently Dx Stage 4 non-small cell carcinoma, undergoing chemotherapy.
Looking for IM/Pulmonary Medicine to speak on the initial visits in April/May 2023 with the standard of care to monitor large bullous lesion. Are PFT results sufficient to allow PRN follow up? regular imaging? Referral?
2 screenshots attached are last note from Pulmonary MD and his narrative to PFT.
Thank you in advance.
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Do you believe there might have been medical error?
Hi the large bulla is unusual in a young individual. I think routine follow up scans would be warranted. This should have been done at least annually, but since this is atypical , a 6 month CT would have been reasonable.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
surveillance ct scans would have resulted in earlier detection, and this would have been at an earlier stage
What makes you a good expert for this case?
i have reviewed many cases, and have been deposed as an expert, and testified in 3 trials
How often do you encounter cases similar to this one in your practice?
very often. i see a high volume of patients with copd, and do routine ct surveillance, and monitor bullous disease closely
Do you believe there might have been medical error?
The bullous emphysema does not require CT imaging follow-up unless he patient becomes symptomatic, such as developing a pneumothorax. Because the patient is younger than 50 years old now, he did not meet the criteria for lung cancer screening with CT until now. He would have been eligible at age 50. Although it appears that the pulmonologist did not initiate adequate treatment and PFT follow-up, this is unrelated to the current question, as he did not meet the criteria for imaging follow-up. However, the initial CT chest may have shown the tumor, and the radiologist reading the CT may not have detected it. With the information provided, it is not possible to opine on this question, and it would be a more appropriate question for a radiologist than a pulmonologist.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There was no indication for imaging follow-up based on the information provided. However, the 2023 CT report may have missed a lung nodule. A radiologist should review that imaging.
What makes you a good expert for this case?
I am a pulmonary critical care Board-certified physician trained at a reputable institution (Mayo Clinic)
How often do you encounter cases similar to this one in your practice?
I see similar cases on a monthly basis
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