DIAGNOSIS:
ABDOMINAL LUMP
BACKGROUND: Mrs R is 53 years old and attends her GP surgery complaining of pain in the left side of her abdomen. She recently recovered from “gastric flu” but is now worried that she can also feel a lump near the site of the pain. Three years previous she was treated for breast cancer. The patient is examined by Dr T who records a finding of spasm in the right iliac fossa with bloating. He diagnoses post-viral irritable bowel syndrome and prescribes mebeverine. Two months later Mrs R returns to the surgery with
recurring abdominal pain though she reports that the medication did help initially. She can also still feel a lump in her abdomen. On this visit Dr T orders a full range of blood tests but does not examine the patient’s abdomen. Five days later the results of the blood tests arrive and are
reviewed by a locum GP – Dr N. All are normal apart from a marginal drop in haemoglobin to 113. Dr N highlights “slight anaemia” in the notes but judges it not to be significant enough for a patient recall and files the result. Mrs R returns to the GP surgery one month later and
examination reveals a palpable mass. Mrs R is later admitted to hospital for a colonoscopy and biopsy confirms a diagnosis of colon carcinoma, though not one suggestive of spread from breast cancer. A week later she undergoes a hemicolectomy and the cancer is found to have spread outside the bowel. Four months later a letter of claim is received by the surgery naming both Dr T and Dr N. It is alleged that Dr T was negligent in failing to make an urgent two-week cancer referral after the patient presented with ongoing abdominal pain and a palpable
mass. It is also alleged that Dr N failed to flag up the low haemoglobin result which was suggestive of colorectal cancer.
ANALYSIS/OUTCOME: MDDUS – acting only on behalf of our member Dr N – commissions a report from a primary care expert. He considers the actions of Dr T in the first consultation and finds no fault in not making an urgent referral at this stage, accepting that the lump could have been interpreted as a spasm or bloating. In regard to the second consultation, he is of the opinion that
the failure here to examine the abdomen constituted negligence. An examination would have likely revealed the presence of the mass and led to urgent referral. It is also unclear why Dr T ordered the blood tests, as the clinical notes are poor. Considering Dr N’s involvement the expert is of the opinion
that the notes did not make it explicit as to why Dr T had ordered the blood tests. In this context he contends that although a marginally low haemoglobin result might be consistent with bowel cancer it is not indicative of it – and that Dr N’s actions in not issuing a recall of the patient do not constitute negligence. MDDUS responds on behalf of Dr N and he is dropped from the proceedings.
KEY POINTS •
•
Ensure that the clinical notes reflect diagnostic thinking; just recording results is not adequate.
Consider alerting the requesting clinician to potentially relevant results if the rationale for the test is unclear.
TREATMENT: NO PROPHYLACTIC ANTIBIOTICS
BACKGROUND: Mr D is a 48-year-old self-employed lorry driver. He attends the dental surgery complaining of severe pain in his lower right jaw. The dentist – Ms J – examines the patient and notes a large restoration in LR5 and that the tooth is tender to percussion. A periapical radiograph reveals a deep apical abscess. Ms J discusses treatment options with the patient and Mr D opts to have the tooth extracted. The tooth is removed uneventfully and the patient is sent home with instructions on routine post-operative care. Three days later the patient returns to the surgery for an
emergency appointment having already been to see his GP. He is suffering submandibular swelling with trismus and difficulty swallowing and breathing. Ms J checks that the patient has not already been prescribed antibiotics and then urgently refers him to the local A&E. He is admitted to hospital to have the area incised/curetted and is treated with IV antibiotics. The infection is slow to clear and Mr D is out of work for three weeks. Two months later the dental surgery receives a letter of complaint from Mr D claiming that Ms J’s failure to prescribe an antibiotic after his extraction led to “serious complications”
WINTER 2016 resulting in his prolonged recovery and loss of earnings.
ANALYSIS/OUTCOME: Ms J contacts MDDUS and an adviser provides assistance in drafting a reply to the complaint. First the dentist expresses regret at the suffering and inconvenience experienced by Mr D, and then she explains that prophylactic antibiotics are not routinely prescribed in extractions and that this protocol is based on well-accepted clinical guidelines. She further states that nothing in Mr D’s clinical
presentation suggested that his symptoms would not resolve with extraction, and the (relatively) rare complication could not be attributed to any negligence on her part. The letter concludes with advice on contacting the health ombudsman if the patient wants to pursue the complaint further.
KEY POINTS •
•
Ensure the practice has a standard protocol on the prescribing of antibiotics.
Be vigilant for any signs of spreading infection when treating dental abscesses.
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