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Balancing risks

10 September 2009

Miss G was a 36-year-old medical receptionist who worked in a teaching hospital. She was under the care of a haematologist for chronic idiopathic thrombocytopenic purpura, diagnosed when she was 13. She had a BMI of 42 and no other relevant past medical history.

Miss G presented to her GP, Dr H, with lower back pain that had been present for two weeks. The pain radiated down her right leg mostly to the calf but sometimes also to her foot. She had twisted getting up from a chair at work and thought this may have been responsible.

During the consultation she also complained of generalised abdominal discomfort, which had come on about the same time. She was prone to constipation and agreed with Dr H that her diet could be better. Miss G did not have any loss of appetite or weight and she had no diarrhoea or vomiting. Dr H could not elicit any more specific details of gastrointestinal problems in the history.

He examined her abdomen which he noted to be soft and non-tender, without organomegaly and examined her spine and lower limbs. He recorded that she had decreased straight leg raising on the right, and was neurologically intact.

Dr H diagnosed sciatica and gave her some exercises, advising her to return within two weeks if things didn’t settle. She told him her back pain was severe and asked him for something stronger than the Ibuprofen which she had been taking. Miss G had no history of asthma or peptic ulcer disease and Dr H prescribed a course of Diclofenac.

Two weeks later she saw another doctor at the practice, Dr M. Miss G was unhappy that her pain was still present, but felt the Diclofenac was helping and asked Dr M to prescribe her some more. Dr M also examined Miss G’s abdomen at this visit and she too noted normal findings. However, in view of her weight and Miss G’s family history of gallstones, she ordered some blood investigations including FBC U and E LFTs amylase and requested an upper abdominal ultrasound.

Miss G’s bloods were all normal, apart from the platelet count of approximately 70 x 109/L per microlitre.

One week later she presented to the A&E department with sudden onset of severe abdominal pain, haematemesis and fresh rectal bleeding. She underwent emergency surgery for a bleeding duodenal ulcer. Over the ensuing days there were further complications and, unfortunately, Miss G died after she developed peritonitis, due to perforation of the ulcer.

The investigation which followed looked at the events leading to her admission to hospital and, in particular, the issue of the GPs’ NSAID prescribing, in view of her history of thrombocytopenia.

Expert opinion

Experts agreed that a platelet count of 70 x 109/L would not be a contraindication for prescribing Diclofenac. In view of the clinical picture it was appropriate. They also found the management and investigations for Miss G’s abdominal pain to be of a good standard. The case was discontinued after providing a detailed letter of response.

References

  • D Provan et al, Oxford Handbook of Clinical Haematology, second edition: Oxford University Press (2004).
  • George J N, Platelets, Llancet 355:1,531-9 (2000). 
  • GP magazine 27 Jan 2006 
  • www.gponline.com

Learning points

  • The fact that a patient has a poor outcome which gives rise to a complaint against a doctor does not necessarily mean that the complaint is justified.
  • It is important to be aware of relative and absolute contraindications of commonly prescribed drugs.
  • It is important always to be aware of the whole patient history and not just to focus on the current issue.
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