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See and be safe

01 July 2007

Mr B, a 32-year-old car salesman who lived alone, was sent home from work after an episode of diarrhoea and vomiting associated with some central abdominal pain. Initially he thought it was due to the spicy meal he had eaten the night before. He spent the next two days at home with occasional diarrhoea and vomiting, which started to settle by the end of the second day.

Mr B had completely lost his appetite and by the afternoon of the second day he stopped drinking water. His abdominal pain was worse, becoming more constant in nature. By 7pm he was feeling more unwell and was beginning to think it was something more serious than a bad reaction to curry.

He called the out-of-hours GP service and spoke to Dr C. After taking a brief history, Dr C advised Mr B to come to the out-of-hours clinic for a consultation. Mr B was reluctant to come saying that he felt too unwell to travel and asked for a home visit. Dr C explained that he did not feel a home visit was necessary, as Mr B’s diarrhoea and vomiting were settling. He advised him to drink water, take paracetamol and call back if his symptoms got worse.

Dr C made brief notes:

“Telephone consultation with Mr B. 2/7 Hx of diarrhoea and vomiting now settling, associated with central abdominal pain. Likely gastroenteritis. Advice given.”

The following day Mr B felt more unwell with severe abdominal pain. He went to his local surgery and saw his own GP, Dr F, who noted that he looked flushed and in pain. Examination revealed a rigid, tender abdomen and Dr F arranged immediate transfer to hospital via ambulance where Mr B was seen by the surgical team. Mr B underwent laparotomy for a perforated retro-caecal appendix. Mr B had no previous medical history and was fairly fit from regularly playing football and attending a gym. During the operation Mr B decompensated and went into septic shock, needing inotropic support during the anaesthetic and ICU care for three days post surgery. Mr B spent a total of 16 days in hospital and, despite the complications, eventually recovered well.

Expert opinion

The expert opinion on this case was that the diagnosis of appendicitis could have been made the previous evening and the delay was unacceptable. Dr C’s notes suggested that he did not take a thorough history over the phone and, having decided to offer the patient an out-of-hours appointment, he should have provided a home visit if the patient said he was too unwell to attend. A timely diagnosis of appendicitis would have avoided the complications and lengthy and difficult recovery. On this basis the claim was settled for a moderate amount to compensate Mr B for his pain and suffering.

Learning points

  • A thorough history requires thorough documentation. In this case the record of this consultation was inadequate and did not include possible differential diagnoses. This led to the missed diagnosis of a serious condition.
  • If a doctor advises a patient that they need to be seen but the patient refuses to come in there is still a duty to take whatever action is reasonable in the circumstances. In this case it was a definite clue as to how unwell the normally fit patient had become.
  • Telephone consultations require extra care in history taking. Doctors assimilate a lot of information regarding a patient’s condition by seeing them. When visual clues are not available a thorough history is all the more important. If in any doubt it is always better to see the patient.

Further information

  • Car J, Sheikh A, Telephone Consultations, BMJ ;326:966–9 (2003)
  • See www.gpnotebook.co.uk. Follow links to “surgery” to find information regarding typical and atypical presentation of appendicitis, including retro-caecal appendicitis.
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