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A rare diagnosis that seemed common

Post date: 01/10/2019 | Time to read article: 4 mins

The information within this article was correct at the time of publishing. Last updated 01/10/2019

Mrs K, a 42-year-old insurance clerk, had a history of dysmenorrhea for which she took the combined oral contraceptive pill (OCP). 

She contacted her GP practice and spoke to Dr F to say that she had experienced heavy bleeding with clots that morning, despite the OCP, and had suffered with griping abdominal pain the evening before, which had now settled. Dr F suggested a trial of tranexamic acid to take as needed when Mrs K’s periods were heavy, and advised her to book an appointment for a pelvic examination.

Mrs K attended the surgery for a face to face appointment some four weeks later, complaining of ongoing heavy periods and abdominal pain, and was reviewed by Dr A. Pelvic examination was found to be difficult due to Mrs K’s obesity and heavy bleeding and Dr A referred her for a pelvic ultrasound scan as well as requesting a range of blood tests, including a full blood count and CA125. The blood tests revealed Mrs K to be slightly anaemic, which was attributed to the heavy menstrual bleeding. 

The ultrasound scan took place two weeks later and revealed two large fibroids. A referral to gynaecology was recommended. Dr F discussed the results with Mrs K over the telephone and established that Mrs K was experiencing bloating after eating, with intermittent abdominal pain, and that she wished to be referred to gynaecology for consideration of surgery. A referral to gynaecology was duly made.  

A further two weeks passed and Mrs K contacted the surgery again, undertaking a telephone consultation with Dr F where she described an episode of severe abdominal pain throughout the night that had now settled. This was considered to be due to the fibroids and mefenamic acid was prescribed.

One week after this Mrs K underwent a further telephone consultation with Dr F, complaining of ongoing abdominal bloating, and three episodes of vomiting the previous day. It was noted that Mrs K tended to vomit when her period was due and she was prescribed codeine and paracetamol as she was finding mefenamic acid to be ineffective. Her gynaecology appointment was noted to be due in two weeks’ time.

The gynaecology team repeated the pelvic ultrasound and, due to poor views, requested an MRI scan for better imaging of the fibroids. This revealed a very large fibroid and Mrs K was counselled for laparoscopic hysterectomy, although she was advised she needed to lose weight before this could take place.

Over the next few months, Mrs K continued to present to the GP practice complaining of spasmodic upper abdominal pain, vomiting and bloating. A diagnosis of biliary colic was considered and she was referred firstly for an ultrasound scan to assess for the presence of gallstones, and then to the gastroenterology team. Although the ultrasound scan did not demonstrate gallstones, both the gastroenterology team and GPs continued to consider biliary colic was the most likely cause for her ongoing but intermittent symptoms.

Mrs K was ultimately admitted to hospital with severe abdominal pain and a raised temperature, suspected to be caused by ascending cholangitis. However, investigations revealed a small bowel stricture and she underwent an emergency laparotomy and small bowel resection. Histology demonstrated a small bowel adenocarcinoma. She was advised to undergo adjuvant chemotherapy.

Mrs K subsequently brought a claim against Dr F, alleging that she was experiencing severe pain at the time of the initial telephone consultation and should have been advised to attend the practice the same day for a face to face appointment.

It was also alleged that subsequent to reporting an episode of severe abdominal pain that had lasted throughout the night, Dr F should have arranged a face to face same day appointment for examination and review, and again at the time Mrs K reported vomiting.

Had she been reviewed in person on these occasions, it was alleged that she would have been referred to secondary care earlier and the tumour would have been identified at an earlier time point, therefore preventing several months of unpleasant symptoms and allowing surgery to be performed in an elective manner.

Further allegations were made against other clinicians who had reviewed Mrs K during this time.

Outcome

The case was considered by Medical Protection’s medical and legal team, and Dr F was considered to have acted appropriately. The team also felt that it was unlikely that, even had Mrs K been seen face to face on any of these occasions, or referred sooner to secondary care, the tumour would have been identified significantly earlier than it was.

A GP expert was instructed. The expert was clear that, on the basis of the medical records and Dr F’s comments, it was not mandatory to offer a face to face appointment the same day as any of her telephone consultations.

The expert did, however, comment that had symptoms been ongoing at the time of the consultations, then Dr F should have established the severity of the pain or vomiting and likely offered a same day appointment for review and examination.

On receipt of the expert report, the case was again fully reviewed by Medical Protection’s medical and legal team and it was agreed that a letter of response, defending the actions of Dr F, should be drafted, and that the offer of early settlement by Mrs K’s solicitors should be rejected.

Following receipt of the letter of response, Mrs K’s solicitors discontinued the claim against Dr F.

Learning points

•             Comprehensive and unambiguous documentation of the patient’s symptoms at the time of a telephone consultation is vital should the history obtained ever be challenged at a later date.

•             The need for a face to face appointment should always be considered, especially if the patient is a poor historian or there is doubt about the nature or severity of the symptoms.

•             If a patient is repeatedly contacting the surgery for telephone consultations about the same symptoms, it may be prudent to offer a face to face appointment to discuss the symptoms further and perform any appropriate examination or investigations.

•             In the event a patient’s symptoms do not settle, it may be advisable to reconsider the working diagnosis in light of the information available and weigh up whether an alternative, perhaps rarer, diagnosis may be the cause.

•             Clinicians should be mindful that a patient may have more than one pathology contributing to their symptoms. 

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