Ms S, a 20-year-old secretary, had suffered varicose veins of her left leg and saw her GP, Dr G. She had also noticed that she had been putting on weight around her tummy. Dr G recorded her weight as 67kg and advised on weight loss to alleviate the symptoms of her varicose veins.
Seven years later Ms S had her varicosities treated with sclerotherapy. She had been doing her best to lose weight but now weighed 77kg and noticed that all the weight seemed to be on her tummy. Dr G advised taking more exercise.
Three years later her weight had increased to 87kg. A vigorous exercise programme successfully reduced it to 72kg but Ms S still complained of tummy swelling. Her varicose veins were worsening and now bilateral. Dr G referred her to a local hospital for varicose vein surgery. The admitting house officer noted that Ms S was overweight, recording a normal abdominal examination.
Ms S went back to Dr G due to her tummy swelling. Dr G performed a pelvic examination, cervical smear and abdominal examination and reassured Ms S that all was well. Despite this she reattended three months later complaining of lower abdominal pain, backache and urinary frequency. Dr G recorded a normal pelvic and abdominal examination, noting obesity and the absence of abdominal masses. He prescribed ibuprofen and gave Ms S a sick note.
After this Ms S presented to casualty with left-sided lower abdominal pain. She reported that this had troubled her for a year and she’d recently put on a lot of weight. The A&E doctor wrote to Dr G suspecting mittelschmerz as the cause for her pain and noting the significant abdominal swelling, querying whether Ms S might be pregnant.
Ms S went back to the surgery the next day with continuing pain in her left groin. Dr G examined the abdomen and found no abnormality, noting that muscle tone improvement was required. When Ms S returned a month later she saw a practice nurse who wondered whether an ovarian cyst might be causing her symptoms and spoke to Dr G, who then organised an ultrasound scan.
This showed a large solitary cyst arising from the left ovary and occupying most of the peritoneal cavity. Ms S saw a gynaecologist who re-sected the cyst along with her left fallopian tube. The cyst weighed 8kg.
Ms S sued Dr G alleging failure to adequately examine or investigate her swollen abdomen, varicose veins, back and abdominal pain. Ms S claimed adverse psychological consequences due to her delayed diagnosis, caused by extensive scarring and decreased fertility consequent to her salpingectomy.
We took advice from a GP expert who was concerned that an alternative diagnosis to obesity was not sought despite her exercise regimen resulting in significant weight loss without an effect on her abdominal girth. The expert noted that the house officer who saw Ms S in hospital had found nothing untoward, potentially supporting Dr G, but considered that inexperience could have been a reason for this.
The expert was concerned at Dr G’s finding of a normal abdomen after a casualty doctor had noted sufficient swelling to raise the possibility of pregnancy. The expert commented, ‘I have to say that I must doubt Dr G’s clinical competence with regard to examination if he is unable to diagnose an abdominal swelling which only two weeks later was felt to be the size of a 36-week pregnancy.’ A gynaecology expert found this similarly worrying.
Gynaecological advice was that an earlier attempt at investigation should have been made, saving at least two years of discomfort. The expert considered Ms S’s varicose veins were likely due to raised pelvic venous pressure caused by the cyst. Both experts felt that the claim could not be defended. We settled this claim and paid Ms S’s costs.
A swollen abdomen can have many causes. The ‘five F’s’ are a useful guide to the possible causes. They are fat, fluid, flatus, faeces or fetus. Examination of the abdomen in obese patients can be difficult, but where abdominal swelling persists, despite genuine attempts to lose weight, it is wise to examine the patient carefully and investigate, particularly where gross distension is not accompanied by generalised obesity.
Listen to your patients, as they are trying to tell you the diagnosis. Ms S’s repeated attendance with the same problem indicates that she felt something was ‘not right’. The subsequent associated symptoms and the presence of severe lower limb varicosities in a young woman should have prompted Dr G to seek an alternative cause for the swelling.