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The elusive diagnosis

14 September 2014

Mr M, 50 years old, suffered chronic ill-health due to spinal fusion, chronic bronchitis and asthma. He was a regular attendee at the surgery of Drs C and D, with sinusitis. In March 2005, Mr M saw Dr D with a similar complaint and she administered him with a flu jab, particularly as Mr M often failed to attend chronic monitoring clinics. The notes from the consultation said: “Upper respiratory tract infection NOS. Catarrh following URTI 2/52 ago is well. O/E ENT NAD chest flu jab given.”

A year later, Mr M saw Dr D and the notes said: “Acute sinusitis chest clear. Prescription for doxycycline 100 mg (8).” Dr D advised Mr M how to take the doxycycline and told him to return if the symptoms did not resolve. Three months later, in June 2006, Mr M attended the surgery again, this time as an emergency, and saw Dr C. Dr C’s notes said: “[SO] penis. Cough. EM-Cough prod of green sputum and sore scratch of L-side of corona of penis ? infected. Chest clear. RV PRN.” Dr C prescribed Mr M some antibiotics to cover the possibility of both skin and chest infections, and asked Mr M to return if either problem did not clear up.

Three months later, Mr M was again seen by Dr C as an emergency appointment. Mr M presented with a productive cough and a high temperature, and, on examination, there were signs of chest infection at the base of the right lung. Mr M was prescribed antibiotics for a lower respiratory tract infection. Six months later, in February 2007, Mr M saw Dr C with a rash on his glans penis and also on his left hand. Dr C considered that the rash looked like a bacterial infection rather than a fungal infection. He prescribed an antibacterial steroid cream.

Five months later, Mr M consulted Dr C over the phone. Mr M said he was coughing up phlegm and that his ears felt blocked. With Mr M’s previous presentations with chest infections in mind, Dr C prescribed an antibiotic suitable for respiratory tract infections. Six months later, in January 2008, Mr M suffered a stroke. Upon admission to hospital, diabetes was diagnosed. Mr M remained in hospital for three months and afterwards continued to suffer pain and restrictions to his mobility.

Mr M made a claim against Dr C and Dr D, alleging that over the course of his numerous consultations, they had failed to diagnose, treat and monitor his diabetes; failed to diagnose, treat and monitor his hypercholesterolaemia; and failed to monitor his blood pressure.

Expert opinion

MPS instructed GP expert Dr K to report on breach of duty. Dr K raised no criticisms of the care provided by either Dr C or Dr D, and did not consider either to be in breach of duty. However, Dr K did warn that a lack of a screening programme at the surgery, to screen for diabetes in at-risk patients, posed a litigation risk.

Professor V, a consultant physician, reported on causation for MPS. He said that had the diabetes been diagnosed and controlled, together with treatment of his blood pressure and cholesterol, on the balance of probabilities Mr M’s stroke would have been prevented or, at least, delayed for a few years. Professor V deferred to Dr K’s view that there had been no breach in the duty of care.

Due to supportive expert evidence, MPS resolved to defend the case; Mr M’s legal team discontinued the claim and MPS was able to recover some of its costs.

Learning points

  • The NICE guidelines Preventing Type 2 Diabetes: Risk Identification and Interventions for Individuals at High Risk (2012) are aimed at identifying people at a potential high risk of developing the condition; assessing their individual risk with testing; and, if necessary, offering lifestyle advice (such as advice on diet and exercise), to help prevent the condition in people who are at high risk. The guidelines are available at
  • It is important to listen to patients who reattend with recurring problems. Doctors must not let an element of “crying wolf” blind their judgment. Maintain an open mind and be willing to revise an initial diagnosis.
  • A long-running scenario such as this one is ideal for discussion at a ‘significant event’ meeting, to identify whether anything could have been done differently at each stage of Mr M’s treatment.
  • By hari Singh on 04 March 2015 10:53

    The patient presented with rash on penis is suspicious of diabetes. Blood test would have confirmed the diabetes.

    This was missed an opportunity.  

    Dr Hari Singh
  • By Dr Bhate on 04 March 2015 04:29

    Good case review since this is a very common scenario and routine screening tests e g BT, HbA1C are not dealt in emergency appointments, but should have done especially with penile rash etc. However commenting retrospectively on management is always easy.

  • By Dr S .Roy on 26 February 2015 03:26
    Good learning point. Missed opportunity to diagnose Diabetes.

    Dr Roy
  • By Andrew Allen on 26 February 2015 02:44
    Nope - not a 'frequent' attender. Not particularly old. Recurrent genital infection-investigate, a one off, I would not. Not sure there are many learning points here, especially as it never got to judgement. What I have learned, though, is that to avoid litigation I need to investigate 50 year olds with minor infections as if they are going to have a stroke! That's a lot of work.
  • By Martin Stagles on 26 February 2015 11:23

    On the other hand, Mr M's attendances were not all that frequent ....  The story spans almost 3 years, so maybe a routine blood pressure check might have been suggested by the computer notes during that period. 

    But I guess I would have fallen for it as well.

  • By Dr T T Lwin on 25 February 2015 05:00  
  • By Dr Yarra on 25 February 2015 04:57
    Presenting with Penile rash (thrush) was an opportunity to suspect Diabetes in this patient and possibly have checked at least urine and arranged at least for a blood test later, it was possible that was missed opportunity to diagnose Type 2 Diabetes I think.
  • By Dr.Raj on 25 February 2015 01:39  
    Good learning point for all the GPs. Also we should use Pendelton's consultation model ICE.
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