0:00

This is a very sad case.

0:02

Uh, a 47-year-old with shoulder pain after trauma.

0:05

Obviously very hard to pick up the, the fracture

0:08

that is in the spine,

0:09

but somehow, again, a smaller hospital where instead

0:12

of getting a shoulder MRI,

0:13

they ended up getting the whole chest, uh, ct.

0:16

And obviously this, uh,

0:18

this shows the non-displaced fracture through the scapula.

0:23

And I won't, I won't, myself, won't be able to pick this up,

0:27

and I won't blame anyone for missing it.

0:29

But there is a finding on this one.

0:31

So the patient was sent back home, patient was continuing

0:34

to have some, uh, shoulder pain.

0:37

So four to five months later, uh, patient was re-scanned.

0:41

And, and, and unfortunately,

0:43

or unfortunately, uh, again, a chest CT kind of, uh,

0:48

or, or field of view was obtained.

0:50

And you can now see that there is a mass that is along the,

0:55

uh, uh, superior aspect of liver under the diaphragm,

1:00

which was not called, uh, at this time.

1:03

Uh, and, and then about six

1:06

or seven months later, patient was,

1:09

had severe abdominal pain

1:11

and all that turned out to be, uh, colon cancer.

1:15

And at that point, this, uh, CT was again obtained.

1:19

And you can see now, uh, this has almost, uh,

1:22

five times the, so going back to the original ct,

1:26

in retrospect, you can see that there was something there,

1:29

but obviously that's, that's very hard to pay.

1:31

So this, this, this, the, the radiologist

1:36

who read the second CT obviously had a

1:39

definite, a definite miss.

1:41

Uh, so he was involved in the, in the, in, in the lit,

1:44

uh, litigious process.

1:46

But it, it was, it was not all radiology, uh, fault.

1:50

And the other thing was that, yes,

1:53

it was missed on the first scan,

1:55

but by that point, patient was already stage four

1:58

because you could, in retrospect,

2:00

you could see something in the, in, in the liver,

2:02

but still this is a miss that,

2:04

that you really can defend.

2:07

Uh, that, and there was almost eight to nine months, uh,

2:11

difference I think between,

2:12

between the two scans when finally the colon cancer was, uh,

2:15

diagnosed in.