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"One last thing..."

01 May 2009

Mrs F was a married 30-year old dinner lady with two children. She presented to her GP, Dr L, with symptoms of weight loss, palpitations, increased sweating and general restlessness.

Mrs F had no significant past medical history and, other than the combined oral contraceptive pill, was on no other medications. Dr L took a history and examined her, then arranged for some investigations, including thyroid function tests, which confirmed she had hyperthyroidism.

After assessment by the local endocrinology department she was put on appropriate medication and returned to the care of her GP. She attended the surgery several times over the next two months for further blood tests and follow-up appointments. At these appointments, Dr L discussed Mrs F’s condition and the management plan with her. He organised regular monitoring and ensured that she was able to tolerate the treatment that he was prescribing for her.

On two occasions, as Mrs F was leaving the room, she mentioned to Dr L that although she was feeling much better following the treatment for the thyroid problem, she had begun to experience vaginal bleeding after intercourse with her husband.

Mrs F said she had heard that this could happen sometimes when women took the contraceptive pill, and sought reassurance. unfortunately, there was no record made of these discussions in her consultation notes and no action was taken to deal with the reported symptoms.

Over the next year, Mrs F’s care for the hyperthyroidism was reviewed by a local endocrinologist. Her GP, Dr L, did not see her again until almost 12 months later when Mrs F made an appointment with another doctor in the practice, Dr Y. The post-coital bleeding had continued and it had become darker in colour. She was also suffering from intermenstrual bleeding and intermittent discharge.

Dr Y performed a pelvic examination, which was noted in the consultation notes to be “normal” and then made arrangements for Mrs F to return to have a smear test at another appointment with the nurse.

Three weeks later, she was seen at the local emergency department following an episode of heavy vaginal bleeding.

She gave a two-year history of post-coital bleeding and confirmed that she had told her GP, but had been reassured. She was referred to the on-call gynaecologist and investigations including colposcopy and a CT scan revealed an advanced cervical carcinoma.

Mrs F made a claim against the surgery. The patient’s management was considered indefensible and the case was settled for a moderate sum.

Learning points

  • Remember the red flags for referral for gynaecological cancers:
  1. Consider urgent referral for a woman with persistent intermenstrual or post-coital bleeding with a normal pelvic examination.
  2. If lesions suspicious of cervical or vaginal cancer are seen on speculum examination a cervical smear is not needed before referral and a previous negative smear test is not a reason to delay referral. (NICE guidelines).
  3. The first symptoms of gynaecological cancer may be an alteration in the menstrual cycle, intermenstrual, post-coital or post-menopausal bleeding, or vaginal discharge. If a patient reports any of these symptoms the doctor should undertake a full pelvic examination, including speculum examination of the cervix. Review NICE guidelines (or those appropriate to your regional jurisdiction).
  • As noted in previous Casebook reports, once a patient mentions something to you, even in passing or on their way out of your room, you have a duty to take appropriate action. It is useful to remember that the consultation only ends when the patient has left the room. Making a record and asking the patient to make another appointment to discuss the symptoms, in detail, may prevent delays in investigation and diagnosis.
  • Be aware of your responsibilities towards ensuring that patients who miss cervical smear tests attend in the future – for example, by asking opportunistically about their missed tests if they attend for other reasons.
  • If it is not convenient at that time, then make arrangements for the patient to come back at a later date. A detailed record should be made in the notes.
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