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The patient with too many ills

01 May 2010

Mr S was a 45-year-old man who was well-known to his GP. He was an anxious, frequent attendee, who needed to discuss different symptoms and worried about his general health. He had suffered from psychiatric disorders in the past and was a heavy smoker who found it difficult to give up.

Sadly, Mr S’s wife passed away quite suddenly and within a two week period after her death, Mr S’s appointments with his GP, Dr F, increased significantly.

Each time he was seen he presented as more worried, preoccupied and irritable. He would ruminate about his dead wife and the guilt he felt for having outlived her. He also seemed more anxious about his health, describing pains in both his hands and feet, which at times changed colour. Dr F noted that Mr S was showing depressive symptoms of poor sleep, appetite and self-care and diagnosed Mr S to be suffering from major depression. With regards to Mr S’s physical problem, every examination of his hands and feet revealed nothing out of the ordinary. He prescribed an appropriate antidepressant and referred him to the practice counsellor for psychological help.

At Mr S’s last consultation, Dr F’s concern grew, as Mr S was showing increasing signs of self neglect with worsening of his psychiatric symptoms. He therefore arranged for Mr S to be admitted informally to an acute psychiatric ward for assessment and further management. In his referral letter, Dr F listed the depressive symptoms elicited and mentioned the pain in Mr S’s extremities as well as his description of the apparent discolouration. Dr F also included his opinion, that these physical symptoms associated with his hands and feet were signs of progressing somatisation due to Mr S’s worsening mental health.

On the psychiatric ward, Mr S underwent the routine physical examination, and due to the persistence of Mr S about the ongoing symptoms of his hands and feet, assistance was sought and a referral to the physicians was made.

Mr S was reviewed and seen by medical registrar Dr A on three separate occasions. Each time, Dr A made brief inserts into the notes documenting the examination, but only on two occasions included a recording of the pulses. He also documented his impression that it was “possible Raynaud’s phenomenon with acrocyanosis; his psychiatric illness seems to be the worst problem”. He also requested bloods, which apart from a raised ESR returned as normal.

Over the next few weeks, Mr S’s doctor and nurses started to notice the discolouration to his hands and feet, which coincided with increased pain and anxiety. With some urgency the vascular surgeons were called and an arteriogram was arranged. With Mr S’s clinical history and the images produced from the arteriogram, a diagnosis of Buerger’s disease was made. Unfortunately, due to the extent of the disease that was present in Mr S at the time, amputation of numerous fingers and toes had to be performed.

Once Mr S had made a recovery from the operation, he decided to make a claim against Dr A for a delay in diagnosis that he felt could have saved his digits from amputation. The decision went against Dr A due to incomplete documentation and the case was settled for a high sum, reflecting the high ongoing care costs Mr S needed.

Learning points

  • It is notoriously difficult to separate organic physical complaints from those of psychiatric origin. Adding in a new psychiatric diagnosis on top of a life event can make it difficult for the practitioner to keep an open and inquisitive mind. Assessing each new symptom in turn can help reduce the risk of making assumptions.
  • As a doctor seeing a patient for the first time, you aren’t just confronted with the past medical and psychiatric history, but also with opinions formed by the referring professionals. This transference can cloud your judgment and prevent all diagnostic possibilities from being explored. It is a part of good medical practice to maintain an open mind, which may help to uncover previous oversights.
  • Psychiatric patients, due to the nature of their illness, may at times not be the best historians. It is therefore of vital importance to use differential diagnoses to rule out any underlying aetiology. Rare conditions do exist. Consistent good documentation detailing relevant findings keeps medical practice safe and helps in defending a claim.