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A takeaway lesson

A-takeaway-lessonThe following case scenario shows how making detailed records of an examination in an emergency setting can help if a claim is later made – and how you should not be overly reassured by a colleague’s diagnosis.

Mr U, a 39-year-old print worker, attended his local Emergency Centre (EC) one evening with a six-hour history of vomiting and abdominal discomfort. The symptoms had come on shortly after eating a takeaway meal. He was seen by Dr A, a community service officer working on the emergency medicine rotation. Dr A documented a detailed abdominal examination which showed no evidence of an acute abdomen. Dr A diagnosed acute gastritis or early gastroenteritis and advised Mr U to go home, rest, and see his GP the next day if things had not settled down.

By lunchtime the next day, Mr U felt increasingly unwell and had been feverish, so he went to his GP, Dr W. The notes kept by Dr W were somewhat brief and did not record an abdominal examination. Mr U later claimed that Dr W had not examined his abdomen during this consultation and had been dismissive, telling Mr U that he “was reassured that the doctors in the EC were not concerned”.

Dr W had noted that urinalysis showed a trace of blood. Dr W diagnosed a urinary tract infection and treated Mr U with a cephalosporin antibiotic. Twenty-four hours later, Mr U was in severe pain and attended the EC again. He was referred for surgical assessment and underwent a laparotomy, which confirmed the diagnosis of acute appendicitis. Mr U subsequently commenced a claim against Drs A and W, alleging negligence causing a delay in diagnosis, leading to unnecessary suffering.

Expert opinion

This was largely supportive of Dr A and commented that it was unlikely he would find confirmatory signs of appendicitis so early in the evolution of the illness. Dr W’s failure to record an abdominal examination meant that Mr U’s assertion that he had not done so could not be refuted, and it was felt that Dr W had been overly reassured by a colleague’s previous diagnosis.

They were of the view that had he performed an abdominal examination at this stage, he would have been able to find signs of appendicitis or an acute abdomen. The presence of a trace of blood in the urine of a young man complaining of acute abdominal pain was more likely to indicate appendicitis than a urinary tract infection. The case was settled for a moderate amount.

Learning points

  • Do not be overly reassured by a colleague’s previous diagnosis. In the context of an acute illness, symptoms and signs may evolve rapidly, and one should always seek to confirm the same or similar findings to a previous examination before formulating your own opinion.
  • Dr A’s advice to seek further medical help if the symptoms had not settled, and his documentation of this fact, was good medical practice and made his actions defensible.
  • When dealing with an acute illness in an otherwise well person, take care to be thorough and conduct and record an adequate history and physical examination to reassure yourself that you are not missing an important diagnosis.
  • See the following paper, which discusses potential pitfalls that may lead to a failure to diagnose appendicitis in the primary care setting: Bird, S, Failure to Diagnose: Appendicitis, Australian Family Physician, 33(12):1025-6 (2004).

This case originally appeared in Casebook (Vol 18. No. 1 – January 2010).

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