DIAGNOSIS: JUST A TUMMY BUG?


BACKGROUND: A mother attends an emergency appointment at the GP surgery with her four-year-old son Sam. The child had seen his regular GP two days before with vomiting and abdominal pain and was diagnosed with viral gastroenteritis. Sam’s mother was advised that the condition would soon run its course but in the past 24 hours the boy’s symptoms have not improved. Sam is seen by another GP – Dr J. Upon entering the consulting room the boy grows extremely distressed, crying hysterically and clinging to his mother. She explains that Sam is afraid of doctors. Eventually Dr J gives up trying to examine the boy, though he does manage to determine by touch that Sam is not feverish. The boy’s grandmother is in the


waiting room and Dr J suggests Sam wait with her. Dr J observes Sam jump into his grandmother’s lap with no obvious signs of pain or tenderness. In the consulting room, Dr J suggests the boy is still suffering from viral gastroenteritis and advises his mother to keep him hydrated and treat any fever with paracetamol. Two days later Sam attends A&E


with extreme abdominal pain which turns out to be appendicitis. Following surgery, Sam spends four days in hospital recovering. One month later


children with acute appendicitis tend to lie still with their legs drawn up. In observing Sam wriggling about and climbing into his grandmother’s lap he concluded that it was unlikely to be a serious problem. The GP expresses his sincere regret


the practice receives an angry letter of complaint from Sam’s mother.


ANALYSIS/OUTCOME: In the letter of complaint Sam’s mother alleges that Dr J failed to properly examine the boy and dismissed her concerns that he might be suffering with something more serious than a “tummy bug”. As a result Sam suffered for an additional two days before being diagnosed and undergoing surgery.


Dr J contacts MDDUS and an adviser assists him in drafting a letter of response to Sam’s mother. In his response the GP states that when Sam came into the consulting room he was distressed and an adequate examination was very difficult. Even if the examination had been forced it would not have been possible to adequately assess the child for tenderness as the abdominal muscles were tensed with stress. He states that in his experience


for Sam’s additional suffering but explains the difficulty sometimes in diagnosing appendicitis, especially in a distressed child. The GP states further that since receiving the letter he has reviewed his understanding of the presenting features of appendicitis and his approach in examining distressed children. He offers to meet with the family to discuss the matter further. Sam’s family respond to say they are


satisfied with the GP’s explanation and the case is closed.


KEY POINTS • Have a high index of suspicion in symptoms persisting beyond the normal course of a viral infection.


• Develop strategies for coping with distressed children – for example using distractions such as toys or rewards or allowing time for the child to calm down before attempting the examination later.


• Explain clearly to the parents the limitations of the consultation and advise an early return if the symptoms don’t improve.


periodontal disease and her gums are now in a “deplorable state with irremediable bone loss”. In his written response to the complaint, Mr A states that on


first seeing Mrs M he was aware of her history of periodontal disease. In his initial examination the dentist recorded “no gingival swelling” and the treatment plan remained focused on monitoring the patient’s oral condition. He states that the problem with the crown at UL6 was identified and remedied and that he also provided detailed advice on smoking cessation. Mrs M’s decision to self-refer to the dental hospital and her refusal to see Mr A again meant he was unable to provide any further advice and treatment. Mrs M is not satisfied with the practice response and refers the case to the health ombudsman. An investigation is undertaken and the ombudsman upholds certain aspects of her case in regard to dental charges for the treatment but not in regard to the failure to diagnose and treat her periodontal disease.


WINTER 2013


In examining Mrs M’s dental records an independent clinical adviser finds that the patient was informed of the poor state of her gums on numerous occasions in previous years and that she had undergone some treatment with the practice hygienist but had also failed to attend numerous appointments. The adviser can only fault the practice in perhaps not communicating effectively with Mrs M on the significance and importance of gum disease and the necessary routine care to prevent the condition getting worse.


KEY POINTS • Ensure that patients understand clearly the significance of periodontal disease and the likely outcomes should treatment advice be ignored.


• Avoid the charge of “supervised neglect” by using every appointment as an opportunity to remind patients with gum disease of the need to maintain good oral hygiene.


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