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Clinical management of patients

Diagnosis

A misdiagnosis is not necessarily negligent if the diagnosis seems reasonable, but doctors are expected to put themselves in a position to make a reasoned deduction to explain a patient’s signs and symptoms. It is not always the rare-but serious conditions that escape clinicians’ diagnostic skills (although these probably account for a disproportionate number of claims); common conditions such as myocardial infarction can also be missed.

The overwhelming majority of clinical negligence claims in general practice arise from a failure to arrive at the correct diagnosis in a timely manner. There are many reasons for this. Sometimes the presentation is atypical or a disease is masked by another condition. Sometimes the patient is unco-operative or fails to turn up for appointments. Or the patient may have a rare disease whose symptoms mimic a common and less serious condition.

All of the above are understandable reasons for failing to reach a diagnosis, so a diagnostic failure in these circumstances can often be defended as long as the doctor applied reasoning based on the information available to him and made comprehensive notes. There are other reasons for failure to diagnose, however, that are less easily defensible, and that is usually because the doctor failed to gather the right information on which to base the diagnosis.

The essential requirements for making a reasoned diagnosis are:

  • Reviewing the most recent entries in the patient’s records.
  • Taking a relevant history.
  • Carrying out an appropriate physical examination when necessary.
  • Arranging appropriate investigations or a referral when necessary.
  • Making adequate arrangments for follow-up.
  • Being willing to revise your (or a colleague’s) initial diagnosis if the clinical picture changes or the patient doesn’t respond to treatment.
A diagnostic failure in these circumstances can often be defended as long as the doctor applied reasoning based on the information available to him and made comprehensive notes

Reviewing the most recent entries in the patient’s records

It is good practice to review the last few entries in a patient’s records just before a consultation. Sometimes there may be outstanding issues that should be followed up, but there will also be cases where you are seeing the patient for an ongoing problem that is not responding to treatment. As signs and symptoms may evolve between consultations, being able to compare earlier presentations with the current one can provide invaluable clues to a diagnosis.

Eliciting a relevant history

This may include past medical history and family history as well as the history of the patient’s presenting condition.

“The great majority of medical diagnoses, up to 90% in the case of chest pain, for example, are made on the basis of the history alone.”6 By the same token, a great many diagnoses are missed simply because the doctor concerned didn’t elicit a full history, thus missing crucial clues to the correct diagnosis (see the case report, "The red eye" below for an example of the consequences of not asking the right questions or giving sufficient credence to the patient’s reported symptoms).

Case report: The red eye

Mrs O, a 54-year-old secretary with a history of migraine, developed a severe frontal headache, noticing flashing lights and cloudiness in her field of vision. These symptoms came on over about 24 hours. She consulted Dr R, who noted the symptoms of headache, ‘misty’ vision and red eye and diagnosed conjunctivitis, prescribing fusidic acid ointment.

By the next day Mrs O was much worse; she had an excruciating headache, photophobia and vomiting. Her vision was worsening and she requested a home visit. Dr M attended and noted that there was inflammation of the right conjunctiva. Both corneas appeared normal and the pupils were equally reactive. She diagnosed migraine and gave Mrs O an intramuscular injection of diclofenac. Dr M advised Mrs O to attend the emergency department of her local hospital if things didn’t settle within 48 hours.
Dr M advised Mrs O to attend the emergency department of her local hospital if things didn’t settle within 48 hours

Mrs O went to hospital two days later where acute angle-closure glaucoma was diagnosed. After pharmaceutical treatment she underwent a right-sided trabeculectomy a few days later. Mrs O’s vision was seriously and permanently impaired in both eyes. She was registered partially sighted and her ophthalmologist anticipated that she would be registered blind within five years.

Mrs O made a claim naming Drs R and M, alleging a failure to suspect or diagnose acute glaucoma as the cause of her symptoms. A GP expert discussed the case with Dr M, who reported that Mrs O had not mentioned any problems with her vision; this, combined with the absence of corneal or pupillary signs, had led her to reject a diagnosis of acute glaucoma.

Despite this, the expert felt that Dr M’s actions would be difficult to defend; even if this symptom was not volunteered, it should have formed part of Dr M’s routine assessment, been directly asked about and documented in the notes. Mrs O had given a clear history of visual cloudiness to Dr R on the preceding day.

The 48-hour delay in Mrs O’s ophthalmological assessment had led to severe and irreversible damage to both eyes with no prospect of recovery

The expert felt that the combination of severe pain, visual impairment and red eye should have prompted Dr R to seek an emergency ophthalmological opinion after Mrs O’s first presentation.

An ophthalmology expert concluded that the 48-hour delay in Mrs O’s ophthalmological assessment had led to severe and irreversible damage to both eyes with no prospect of recovery. The claim was settled out-of-court, and liability shared equally between the two GPs.

(Based on The Red Eye? MPS Casebook 13(4) 2005.)