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A pain in the leg

01 September 2012

Miss Y was a 36-year-old housewife with three children. She presented at her GP surgery with spontaneous pain in the leg, which was associated with a cramping sensation and pins and needles in her left foot. Miss Y saw her GP Dr C, and upon entering the consultation room raised the possibility of DVT, as she had been recently reading about DVTs in the news and her symptoms appeared similar. Dr C took a careful history and, with Miss Y’s suggestion in her mind, concentrated particularly on the possibility of a DVT.

She asked if there was any swelling of the legs, shortness of breath, chest pain or haemoptysis. Miss Y had confirmed that she had none of these symptoms. She asked if there was any personal or family history of thromboembolism, which there was not. She also asked about smoking history and Miss Y had stated that she had never smoked. Dr C also examined Miss Y thoroughly.

She had found her pulse to be 70 beats per minute and her respiratory rate to be 12 breaths per minute. She noted that Miss Y’s chest was “clear to auscultation”. She had measured calf circumferences and found them to be equal. She had also documented that she could palpate normal pulses in both her legs and feet. Dr C could not find anything wrong but had written that she had told Miss Y to reattend if she developed any swelling in the legs, shortness of breath, chest pain or hemoptysis.

Ten days later, Miss Y collapsed suddenly and was found dead at home. The postmortem found the cause of death to be a pulmonary embolus secondary to a DVT. Her family were devastated and brought a claim against Dr C because of failure to diagnose.

Dr C could not remember the case but her note-keeping was excellent. She had documented a thorough history, a full examination and sensible safety-netting advice. Despite the fact that she did not make a diagnosis of the DVT, the case was found to be defensible because Dr C had done everything she could and should have done. The case was successfully defended.

Learning points

  • Good note-keeping is not only good practice, but it will make a possible defence much easier if needed.
  • A DVT can be difficult to diagnose clinically and GPs should have a low threshold for referring patients for ultrasound scanning to either confirm or refute the diagnosis.