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Casebook Vol. 21 no. 1 - January 2013

On the case

Dr Ming-Keng Teoh, Head of Medical Services (Asia), introduces this issue’s round-up of case reports.

When treating patients who attend the surgery frequently, especially within a short space of time, it can be all too easy to be blinded by a familiar diagnosis based on pattern recognition, particularly if it is a commonplace, and seemingly innocuous, condition.

The safest approach when treating frequent attenders is to go back to basics: document a thorough history and be prepared to re-examine the patient if their symptoms change. Back pain is one of the most common complaints seen in general practice. Doctors may easily discount it, but it is important to remember that a small proportion of such cases mean serious or life-threatening pathologies.

In “Back with back pain”, Mrs S’s recurrent urine infections, in association with back pain, were found to be co-existing with non-Hodgkins lymphoma. Despite a claim being made against Dr F for failing to refer Mrs S earlier, Dr F’s good documentation of the history and each examination meant that this was discontinued. Experts found that there was a careful, well-documented assessment of Mrs S on every occasion, which showed that at no time was an emergency referral warranted.

In direct contrast, a claim against Dr W for a missed SAH in “Take me seriously” had to be settled for a high sum. There was no evidence in the records that Dr W had taken any history or performed an examination. As a result, Mrs T’s fatal SAH was missed. One consultation was recorded simply as "Migraine. Prescribed some painkillers.” Despite Mrs T returning to the surgery several times with recurrent headaches, and later with pain shooting down the back of her neck, the potentially life-threatening causes of her recurrent headaches were not considered.

Similarly, in “Where the heart is”, Mr R’s high blood pressure was attributed to anxiety before more sinister pathologies were excluded. His risk factors for cardiopulmonary disease should have been considered when taking the history, examining and arranging follow up tests.

The learning points from all these cases are that potentially serious pathologies should never be discounted before a proper assessment has been made and a detailed history taken. Comprehensive records should be made of both.

Case Reports