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The forgotten problem

01 February 2005

Physicians often care for patients with extremely complex clinical presentations and multiple diagnoses. In such a situation, it can be hard to keep track of all the relevant problems and investigation results.

These were the circumstances following Mrs P’s admission under the care of a general medical team, after being taken by ambulance to the Emergency Department with symptoms of feeling weak and dizzy.

Mrs P, a retired teacher, was 65 years old and had been a heavy smoker. She suffered from intermittent claudication and peptic ulcer disease; this latter diagnosis was inactive and Mrs P had no gastrointestinal symptoms or need for medication.

She described several recent episodes of transient monocular visual loss accompanied by left-sided limb weakness and dysaesthesia, consistent with transient ischaemic attacks (TIAs). Her ocular symptoms were likely due to amaurosis fugax.

She was mildly hypotensive and an initial ECG showed sinus tachycardia with right-bundle-branch block. She had a mild normochromic, normocytic anaemia with Haemoglobin (Hb) at 10 g/dl. A coagulation screen was normal and a faecal occult blood test was reported as positive. Cardiac enzymes were unremarkable.

Mrs P was anticoagulated with heparin and warfarin to treat a suspected diagnosis of recurrent TIAs, and screened for possible myocardial infarction.

By the following day her tachycardia had settled and she was asymptomatic and normotensive. A carotid duplex ultrasound scan revealed almost complete stenosis of the right internal carotid artery. Her Hb was now 8.9 g/dl. Mrs P remained stable over the next few days but did have further TIAs. She remained neurologically intact. Her team arranged a CT scan of her head and sought a vascular surgical opinion.

Five days after she was admitted, Mrs P had further episodes of hypotension and weakness. A repeat ECG showed non-specific ST-segment depression. Mrs P was transferred to CCU as a suspected case of unstable angina or myocardial infarction.

After her transfer, that day’s FBC result became available, showing that her Hb had fallen to 5.4 g/dl. At this point her team started fluid replacement, arranged blood transfusion and gave intravenous ranitidine.

Unfortunately, Mrs P developed bradycardia and severe hypotension within a few hours of arriving on CCU, then had a cardiac arrest from which she could not be resuscitated.

A postmortem showed evidence of severe ischaemic heart disease, myocardial infarction (the cause of death), marked pulmonary oedema, gross peripheral/cerebro-vascular disease, and peptic ulceration with recent haemorrhage.

Mrs P’s family brought legal proceedings, alleging negligence by the hospital and team that cared for her in her last days.

Expert opinion

An expert physician thought that the treatment the medical team had given to Mrs P was appropriate, and agreed it was necessary to anticoagulate her, at least initially.

However, he felt that their failure to prescribe appropriate prophylaxis against peptic ulcer disease, in an anaemic patient with a known history of peptic ulcers, was a significant omission.

The consultant in charge of Mrs P’s care agreed with this assessment; the failure to act on the initial anaemia and positive faecal occult blood test, along with a failure to note and remedy the falling Hb level, meant that gastrointestinal haemorrhage, while not the primary cause of Mrs P’s death, had certainly contributed to it and had not been appropriately monitored or treated.

It was agreed that more attention to this problem would have meant that the anticoagulation would have been stopped, improving Mrs P’s prognosis. We settled the case for a sum equivalent to £75,000.

Learning points

  • Multiple conditions - When treating people with multiple diagnoses, a problem list is an invaluable tool. If it is drawn up on admission and reiterated at each subsequent review, with problems designated as active or inactive, it significantly decreases the chances of overlooking important aspects of patient care, or forgetting to chase necessary results. Problem lists are useful tools for preventing the treatment of one condition to the detriment of another. They are also a valuable tool in outpatient and primary-care settings as they focus the mind on active problems while reminding you of dormant issues that may still be relevant.
  • Handover: The BMA Junior Doctors Committee has recently published guidance on clinical handover for clinicians and managers,1 endorsed by representatives of the National Patient Safety Agency and the GMC.
  • This information would be useful for those working outside of the UK if there are no specific local guidelines, and is available at www.bma.org.uk.
  • Anticoagulation: This must be monitored carefully, preferably according to a pre-defined protocol. Regular review of the initial indications and any developing contraindications is advisable.
  • Investigation results: Keeping track of results is important, particularly in complex secondary-care scenarios. Any system is only as good as the people who administer it, so regular training and review of its efficacy, together with monitoring through audit are recommended.

As we move towards ‘paperless’ clinical records, the safeguard of signing hard copies of results should be replaced by an equivalent measure. If you order a test, you ought to know and consider the result.

‘Stress’ ulceration: When patients are acutely unwell they are more prone to peptic ulceration; this may have been the case here, or it may have been reactivation of an old disease.

For a useful tutorial on this condition, see www.ccmtutorials.com/support/ulcers/page_01.htm.

A recent review is recommended to those with responsibility for patients in acute care areas.

  1. Safe Handover: Safe Patients, BMA Junior Doctors Committee. BMA, London.
  2. Spirt MJ, ‘Stress-Related Mucosal Disease: Risk Factors and Prophylactic Therapy.’ Clin Ther, 26(2):197–213 (2004).
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