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Casebook Vol. 20 no. 2 -
May 2012

From the case files...

Dr Nick Clements, Head of Medical Services, introduces this issue’s round-up of case reports, a number of which focus on missed infections

In “Where is the consultant?”, Mr W’s endocarditis was missed by the cardiologist Dr H, who only saw him once during his inpatient stay. Mr W was not consulted about his progress, results of investigations or plans for discharge or follow-up. In this case, team working and fractured continuity of care created an “I thought you did it” situation; required tasks were not completed and an outpatient clinic appointment was not arranged.

Safe systems should be in place to ensure that results are acted upon and that the relevant investigations are carried out. Similarly, there was poor continuity of care in “A pain in the neck”. Mr P was not fully examined on any subsequent visits to his GP, Dr W, despite progression of his neurological symptoms. The problem here was Mr P’s hostile and challenging behaviour, which meant that clinical examination was usually difficult. All the healthcare professionals involved in his care missed the large tubercular abscess in his neck, which resulted in Mr P becoming tetraplegic. This case is a pertinent reminder that despite an aggressive or difficult patient, you should maintain a professional approach and rule out any underlying pathology. To do otherwise is indefensible – expert opinion found Mr P was not examined early enough, despite repeatedly attending with his symptoms.

Preconceptions of a particular patient can hinder diagnosis. In “Crying wolf” Mrs Z’s multiple calls went unheeded, and similarly, in “Suffer the little children”, M’s generally unhealthy demeanour and frequent contact with the GP masked the extent of her symptoms. Her puffy eyes were put down to “looking rather ill, as usual,” rather than the severe bilateral orbital cellulitis she was eventually diagnosed with and which resulted in her becoming blind.

Extra care should be taken with frequent attenders, particularly if there are repeated calls – always revisit your diagnosis if symptoms persist or appear to be getting worse. You should have a low threshold for examination when conducting telephone consultations, and, as this case shows, effective triage is essential. Non-clinical staff should be educated to recognise potential red flag symptoms and pass on vital information to the healthcare team.