cASe fileS
“one last thing...”
poor record keeping and inadequate handovers can
have serious consequences for patients. in this case an
important diagnosis was not made until it was too late
M
rs f was a with her husband. colposcopy and a ct scan
married 30-year- Mrs f said she had heard revealed an advanced
old dinner lady that this could happen cervical carcinoma.
with two children. she sometimes when women Mrs f made a claim
presented to her gp, took the contraceptive pill, against the surgery experts
dr l, with symptoms of and sought reassurance. considered the patient’s
weight loss, palpitations, unfortunately, there management indefensible
M
o
increased sweating and was no record made and the case was settled.
.
c
general restlessness. of these discussions in
t
o
o
H
Mrs f had no significant her consultation notes
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K
past medical history and, and no action was learning points
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o
other than the combined taken to deal with the 1
/
i
s
d
oral contraceptive reported symptoms. ■ remember the red
r
p
a
pill, was on no other over the next year, flags for referral for
l
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o
medications. dr l took a Mrs f’s care for the gynaecological cancers:
W
o
history and examined her, hyperthyroidism was 1. consider urgent
n
s
then arranged for some reviewed by a local referral for a woman
investigations, including endocrinologist. Her gp, with persistent ■ When a patient mentions
thyroid function tests, dr l, did not see her again intermenstrual or something to you, even
which confirmed she until almost 12 months post-coital bleeding, in passing or on their
had hyperthyroidism. later when Mrs f made even with a normal way out of your room,
after assessment by an appointment with a pelvic examination. you have a duty to take
the local endocrinology locum in the practice, dr 2. if lesions suspicious appropriate action. it is
department Miss f was put Y. the post-coital bleeding of cervical or vaginal useful to remember that
on appropriate medication had continued and it had cancer are seen on the consultation only
and returned to the care become darker in colour. speculum examination ends when the patient
of her gp. she attended she was also suffering from a cervical smear has left the room. Making
the surgery several times intermenstrual bleeding result is not needed a record and asking
over the next two months and intermittent discharge. before referral and the patient to make
for further blood tests and dr Y performed a pelvic a previous negative another appointment to
follow-up appointments. examination, which was smear test is not a discuss the symptoms,
at these appointments, noted in the consultation reason to delay referral. in detail, may prevent
dr l discussed Mrs notes to be “normal” and (nice guidelines). delays in investigation
f’s condition and the then made arrangements 3. the first symptoms of and diagnosis.
management plan with for Mrs f to return to have gynaecological cancer ■ Be aware of your
her. He organised regular a smear test at another may be an alteration responsibilities towards
monitoring and ensured appointment with the nurse. in the menstrual ensuring that patients
that she was able to three weeks later, she cycle, intermenstrual, who miss cervical smear
tolerate the treatment that was seen at the local post-coital or post- tests attend in the future
he was prescribing for her. emergency department menopausal bleeding, – for example, by asking
on two occasions, as following an episode of or vaginal discharge. opportunistically about
Mrs f was leaving the heavy vaginal bleeding. if a patient reports any their missed tests if they
room, she mentioned she gave a two-year of these symptoms attend for other reasons.
to dr l that although history of post-coital the doctor should ■ if it is not convenient
she was feeling much bleeding and confirmed undertake a full pelvic at that time, then
better following the that she had told her gp, examination, including make arrangements
treatment for the thyroid but had been reassured. speculum examination for the patient to come
problem, she had begun she was referred to the of the cervix. review back at a later date. a
to experience vaginal on-call gynaecologist and nice guidelines at detailed record should
bleeding after intercourse investigations including www.nice.org.uk. be made in the notes.
14 sessional gp | voluMe 1 | 2009 www.mps.org.uk
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