In a patient with a 5 cm septated hypoechoic pelvic mass identified on renal ultrasound and a radiologist’s recommendation for contrast‑enhanced CT pelvis, what actions and specialty referral responsibilities are appropriate for the primary‑care physician, and how could failure to follow them be viewed as medical negligence?

Standard of Care for PCP Management of Incidentally Discovered Pelvic Mass

A reasonably prudent primary care physician who receives a radiology report documenting a 5 cm septated pelvic mass with an explicit recommendation for contrast-enhanced CT pelvis must personally review the complete imaging report, order the recommended follow-up imaging within 1-2 weeks, and refer to gynecology immediately—failure to do so constitutes a clear departure from the standard of care that directly endangers patient safety by delaying diagnosis of potentially malignant disease.

Core Responsibilities of the Primary Care Physician

Mandatory Review of Complete Radiology Reports

• PCPs must personally review the full radiology report, not rely on verbal summaries or discharge documentation from other providers. 1
• The PCP had direct EHR access to the complete ultrasound report identifying the 5 cm mass and CT recommendation but documented only "no hydronephrosis or renal calculi"—this represents a critical failure in the fundamental duty to review diagnostic test results. 1
• Research demonstrates that approximately 5% of radiology recommendations result in clinically significant "open loops" where recommended actions are never completed, posing substantial clinical risk. 1
• The ED's characterization of the ultrasound as "negative" does not absolve the PCP of independent review responsibility—PCPs cannot delegate their clinical judgment to emergency physicians who may have different diagnostic priorities. 2

Immediate Action on Radiologist Recommendations

When a radiologist explicitly recommends additional imaging (CT pelvis with contrast), this constitutes an actionable recommendation requiring completion within the specified or clinically appropriate timeframe. 1

• Factors associated with successful "loop closure" include: absence of contingency language (the recommendation was direct), shorter time frames, and direct radiologist-to-physician communication. 1
• The 4+ month delay from identification to re-discovery represents an egregious failure of the closed-loop communication system that should exist for critical findings. 1
• The radiologist's recommendation for CT pelvis with contrast was unambiguous and non-contingent—there was no clinical justification for not ordering this study immediately.

Appropriate Imaging Follow-Up

For a 5 cm septated hypoechoic pelvic mass, the appropriate next step is either contrast-enhanced CT pelvis (as recommended) or preferably MRI pelvis with and without IV contrast, not observation alone. 3

• The American College of Radiology recommends ultrasound as first-line imaging for adnexal masses, but when a mass is indeterminate (septated, 5 cm), MRI pelvis with and without IV contrast is the preferred modality over CT because it provides superior soft tissue characterization with 92% overall accuracy using the O-RADS MR reporting system. 4, 3
• CT with IV contrast is appropriate for staging when malignancy is suspected, but MRI is superior for characterizing indeterminate masses. 3
• The ACR states that IV contrast is essential because it "identifies enhancing solid tissue components crucial for distinguishing benign from malignant lesions." 3
• Ordering CT abdomen AND pelvis together (not pelvis alone) is critical when malignancy is suspected to assess for metastatic disease. 3

Mandatory Specialty Referral

A 5 cm septated pelvic mass of uncertain etiology requires immediate gynecology referral—this is not optional. 5

• Research shows that only 39.3% of family physicians and 51.0% of general internists self-report referring patients with suspicious adnexal masses to gynecologic oncologists, contributing to high rates of non-comprehensive surgery for ovarian cancer. 5
• The standard of care requires that PCPs recognize when a finding exceeds their scope of practice and refer to appropriate specialists without delay.
• Factors that inappropriately reduce referral rates include rural practice location, solo practice, and high patient volume—none of these excuse failure to refer a potentially malignant mass. 5

Documentation Requirements

The PCP must document:

• Review of the complete radiology report (not just selected findings)
• Recognition of the pelvic mass and its characteristics
• The plan for follow-up imaging with specific timeframe
• Gynecology referral with urgency level
• Patient notification of the finding and its significance

Documenting only "no hydronephrosis or renal calculi" while omitting a 5 cm pelvic mass represents falsification by omission—it creates a false medical record that subsequent providers will rely upon.

Clinical Significance of the Missed Finding

Malignancy Risk Assessment

• A 5 cm septated pelvic mass carries significant malignancy risk that cannot be determined without proper imaging characterization. 4
• Indeterminate adnexal masses have a malignancy rate of 3.6% to 10.7% depending on classification system used. 4
• Size >5 cm is a key feature suggesting potential malignancy and mandates thorough evaluation. 6
• Septations within a cystic mass increase concern for malignancy and require contrast-enhanced imaging to assess for enhancing solid components. 4

Time-Sensitivity of Diagnosis

Ovarian cancer staging and prognosis are directly related to time to diagnosis—a 4+ month delay potentially allows progression from early to advanced stage disease, fundamentally altering mortality and quality of life outcomes.

• The window for optimal surgical management narrows with each passing week as potentially malignant masses grow and potentially metastasize.
• Even if the mass proves benign (such as a fibroid), a 5 cm mass can cause significant symptoms including the documented stress incontinence through mechanical bladder compression.

Connection to Documented Symptoms

The repeated documentation of stress incontinence at three consecutive visits ([DATE], [DATE], [DATE]) while a known 5 cm pelvic mass existed represents a failure to connect clinical symptoms with available diagnostic information. 4

• Pelvic masses can cause or exacerbate urinary symptoms including incontinence through mechanical pressure on the bladder. 4
• The conservative management approach ("increase fluid intake, change pads frequently") was wholly inadequate given the known structural abnormality.
• A reasonably prudent physician would recognize that new-onset stress incontinence in the setting of a known pelvic mass requires investigation of the mass as a potential causative factor.

Medical Negligence Framework

Elements of Negligence

This case demonstrates all four elements required to establish medical negligence:

1. Duty: The PCP owed a duty to the patient to review diagnostic test results, follow radiologist recommendations, and refer appropriately.

2. Breach: The PCP breached this duty by:

   • Failing to review or act upon the complete radiology report
   • Failing to order recommended follow-up imaging for 4+ months
   • Failing to refer to gynecology despite a 5 cm indeterminate mass
   • Documenting only partial findings, creating a false medical record
   • Treating symptoms (incontinence) without investigating known structural pathology

3. Causation: The breach directly caused a 4+ month delay in diagnosis and treatment of the pelvic mass.

4. Damages: Potential damages include:

   • Delayed diagnosis of potentially malignant disease
   • Possible disease progression during the delay period
   • Psychological harm from delayed diagnosis
   • Potential need for more extensive treatment if malignancy progressed
   • Ongoing symptoms (incontinence) that went unaddressed

Departure from Standard of Care

Multiple departures from accepted standards occurred:

• No reasonable PCP would document a renal ultrasound as showing only "no hydronephrosis or renal calculi" when the report explicitly describes a 5 cm septated pelvic mass. This is not a matter of clinical judgment—it is factual misrepresentation.

• No reasonable PCP would ignore an explicit radiologist recommendation for contrast-enhanced CT pelvis for over 4 months. 1

• No reasonable PCP would fail to refer a 5 cm indeterminate pelvic mass to gynecology. 5

• No reasonable PCP would treat stress incontinence conservatively without investigating a known 5 cm pelvic mass as a potential cause. 4

System Failures vs. Individual Responsibility

While system failures contributed (ED miscommunication, lack of automated tracking for critical findings), these do not absolve the PCP of individual responsibility:

• The PCP had independent access to the complete radiology report through the EHR
• The PCP saw the patient at three separate visits with opportunities to identify the finding
• Professional standards require that physicians maintain independent clinical judgment and not rely solely on other providers' summaries 2

Common Pitfalls and How to Avoid Them

Pitfall 1: Relying on Verbal or Summary Communications

Never rely on ED discharge summaries, verbal reports, or other providers' characterizations of imaging studies—always review the complete radiology report personally. 1, 2

Pitfall 2: Documenting Only "Normal" Findings

When documenting imaging results, include ALL significant findings, not just those relevant to the immediate presenting complaint. Incidental findings often have greater long-term significance than the acute issue.

Pitfall 3: Assuming Someone Else Will Follow Up

The ordering physician bears primary responsibility for acting on results—never assume the ED, radiologist, or specialist will ensure follow-up. 1

Pitfall 4: Delaying Specialty Referral

When a finding exceeds your expertise or requires specialist evaluation, refer immediately—do not attempt serial observation of potentially serious pathology. 5

Pitfall 5: Treating Symptoms Without Investigating Structural Causes

When new symptoms arise in the setting of known structural abnormalities, investigate the connection before implementing symptomatic treatment alone. 4

Pitfall 6: Inadequate Closed-Loop Systems

Practices must implement reliable systems to track and ensure completion of radiology recommendations—manual review is insufficient given the 5% failure rate documented in research. 1

Professional and Legal Implications

This case would likely be viewed by medical-legal experts as representing clear negligence:

• The duty was unambiguous (review results, order imaging, refer to specialist)
• The breach was documented (no imaging ordered, no referral made, incomplete documentation)
• The causation is direct (4+ month diagnostic delay)
• The potential for harm is substantial (delayed cancer diagnosis, disease progression)

Expert witnesses would testify that no competent PCP practicing within the standard of care would:

• Omit a 5 cm pelvic mass from documentation
• Ignore a radiologist's explicit recommendation for 4+ months
• Fail to refer an indeterminate 5 cm pelvic mass to gynecology
• Treat mechanical symptoms without addressing known structural pathology

The multiple opportunities to catch the error (three separate visits) and the availability of the information (same health system, EHR access) make this case particularly difficult to defend.