Case Study - Age No Barrier (from the Medical Protection Society, Case Reports)

Age no barrier

A seven-year old girl, MA, complained to her mother of stomach ache. She was usually very stoical, but was complaining and not wanting to play. Her mother, Mrs A, was concerned and rang the surgery to speak to her GP, Dr G.

Dr G told her to give her daughter some paracetamol, but did not document the conversation in her notes. The next day, MA was still suffering so Mrs A requested a home visit. The GP went to their home and quickly diagnosed a UTI without examining the girl and prescribed trimethoprim. Dr G made only very brief notes, just mentioning the abdominal pain and the antibiotics prescribed.

According to her mother, Dr G did not stay very long, did not examine her daughter and did not ask for a urine sample to test. Mrs A asked Dr G whether it could be appendicitis, as the pain was on the right side. Her friend’s daughter had recently had appendicitis, which had been right-sided. Dr G said that MA was “too young for that”.

The following day, MA had started to vomit and seemed in much more pain, despite having taken paracetamol. She was also warm to the touch so Mrs A rang the surgery again. A different GP, Dr P, informed her that “antibiotics take time to start working” and to allow another couple of days to see if she improved. Again, the GP made no record in her notes of their discussion on the phone.

Three days after the pain began, Mrs A took her daughter to the Emergency Department (ED). By this time she looked very unwell. She was pale and was lying very still. She was in a lot of abdominal pain if she tried to move. She was vomiting and could not keep any food or drink down. The surgeons diagnosed acute peritonitis and took her straight to theatre where they found a perforated appendix. MA had a miserable stay in hospital, needing intravenous antibiotics, but she did make a good recovery.

MA got married when she was 29 and decided to try for a family. After two years of trying, she still was not pregnant and so went to discuss this with her GP. She was referred for tests and found to have blocked fallopian tubes and pelvic adhesions.

The specialist thought this was likely to have been caused by the perforated appendix and resultant pelvic adhesions years before. MA was very upset and made a claim against Dr G and Dr P. The claim was settled for a moderate sum. Although Dr G had died by this time, so was no longer in membership, the fact that he was a member of MPS at the time of the incident meant that MPS was able to respond to the claim.

Learning points

• It is very important to examine a patient with abdominal pain. Doctors must adequately assess the patient’s condition, taking account of the history, the patient’s views and, where necessary, examining the patient.¹ Failure to examine the patient’s abdomen made the case indefensible.
• Always be prepared to reconsider a diagnosis made by another doctor.
• Some pathologies, such as appendicitis, are more common in certain age groups, but are still possible in others. Differential diagnosis needs to consider both the usual and the unusual.
• Simple tests like dip-sticks are there to be used and are helpful in evaluating the likelihood of a diagnosis of UTI. Diagnosing a UTI with no evidence may not be safe.
• Clear, comprehensive documentation is an invaluable way to ensure good communication with colleagues when patients are seen by different doctors.
• A good defence is almost impossible without good documentation. Doctors must keep clear, accurate and legible records, reporting the relevant clinical findings, the decisions made, the information given to patients, and any drugs prescribed or other investigation or treatment.²
• There may be long delays between the incident and a claim being made, which demonstrates the strength of occurrence-based indemnity. Claims can be brought years after a doctor has retired, or even died.

References

1. GMC Good Medical Practice 2006, good clinical care, paragraph 2a.
2. GMC Good Medical Practice 2006, good clinical care, paragraph 3f.

From: http://www.medicalprotection.org/ireland/casebook-january-2010/case-reports/age-no-barrier

Thanks to Marwan Al-Qenaie for sharing this case study!

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Newsletter Issue 3: What is the diagnosis?

The following is a challenging case history presented by KMS newsletter team at the June 2009 issue - we hope you got the diagnosis right, if not check the answer right below

"A 56 year-old male, previously healthy, presents with gradual onset of fatigue, insomnia and myalgias over the past few years. Recently he has developed diabetes. On examination he has some skin pigmentation and pain in his hands and knees. What does he have?"

Hereditary Haemochromatosis (HH) is a disease of excessive absorption of iron which is subsequently deposited in different body tissues causing them damage. The pattern of inheritance is autosomal recessive. Haemochromatosis can also be acquired by adding excess iron to the circulation via frequent blood transfusions as necessitated for the treatment of certain diseases (e.g. Haemophilia, Thalassaemia). HH is hard to diagnose because the symptoms are often vague and it takes a long time to develop (age of diagnosis is usually between 40-60 years old). By then, liver damage and other problems are well established. The skin pigmentation and the onset of diabetes (secondary to pancreas damage) are the key clues to diagnosing HH in this case, also known as 'bronze diabetes'. Other symptoms include cardiac abnormalities, early-onset and unexplained joint pain and male sexual dysfunction. Tests to help diagnose HH include: full blood count, hematinics such as ferritin and iron levels; a liver biopsy would provide a definitive diagnosis. The treatment focuses on removing excess iron, either by removing the iron physically (venesection) or chemically using chelators such as desferrioxamine. In fact, this disease is more common in men than women because women naturally lose more iron through menstruation and pregnancy.

References:

R Lim, T Irvine, M S Ahmed, K Abraham and C F Wong. A permanent tan from iron. Kidney International (2008) 73, 898

www.webmd.com