Gut pain - medical case study

DAY ONE

Mr T – a 48-year-old plumber – phones an out-of-hours service on a Sunday afternoon complaining of diarrhoea and vomiting along with colicky pain in his abdomen. He speaks to a triage nurse who advises the patient that he is most likely suff ering from viral gastroenteritis. She advises him to take paracetamol for the pain and to phone back later in the day if the symptoms worsen.

DAY TWO

Mr T attends his GP surgery for an emergency appointment as his symptoms have not improved. He sees Dr K who confi rms a history of vomiting and diarrhoea but with no blood in the stools. He examines the patient and notes a temperature of 36.1 and a soft tender abdomen on palpation with no guarding or rebound. The GP off ers a diagnosis of gastroenteritis and advises the patient to drink plenty of clear fl uids and take co-codamol for the pain. Mr T is told to call back or return to the surgery if the symptoms do not improve or grow worse – or if there are any red fl ag symptoms such as high fever, blood in vomit or stools or worsening/severe abdominal pain.

DAY EIGHT

Mr T attends for another emergency appointment and this time sees a diff erent GP. He is suff ering severe abdominal pain and reports vomiting black bile and passing black stools. The GP immediately has the patient admitted to hospital. Mr T is found to have maximal tenderness and guarding in the right iliac fossa. An X-ray is taken revealing small bowel dilatation. This is followed-up with a CT scan which shows a large pelvic abscess secondary to appendicitis. He undergoes an emergency laparotomy, appendicectomy and a section of small bowel is resected. A loop ileostomy is performed. Mr T slowly improves over the next weeks but has problems coming to terms with his need for a stoma.

FOUR months later the practice is notified of a negligence claim against Dr K for not diagnosing appendicitis timeously and referring Mr T to hospital at a stage when the subsequent complications could have been avoided – preventing the need for an ileostomy. Dr K contacts MDDUS and various expert reports are commissioned including one from an experienced primary care physician. Copies of the patient notes and detailed statements by Dr K and the patient are assessed.

The expert notes that in his statement Dr K contends that the main purpose of his examination of Mr T on Day 2 was to exclude a diagnosis of appendicitis. He states that the common presentation of appendicitis is central abdominal pain spreading down the right-hand side. His standard practice is to examine for evidence of rebound tenderness and guarding which would be indicative of an inflamed appendix. A rigid abdomen suggests a ruptured appendix. His examination of Mr T on Day 2 revealed neither of these fi ndings. Given the patient was complaining of diarrhoea and vomiting of less than 24 hours his diagnosis was gastroenteritis.

Mr T claims that he was “doubled over with pain” on attending the surgery that morning. He states that when the doctor palpated his lower right abdomen he “nearly hit the ceiling”. He further states that he asked Dr K specifi cally if it could be appendicitis but was told it was “only a tummy bug”. He denies having his temperature taken or being asked about blood in his stools, nor being told to come back if his symptoms worsened or if there were any “red flags”.

In addressing the conflicting claims between doctor and patient the primary care expert refers to the patient records. Here he finds contemporaneous and well set-out notes by Dr K detailing the nature of the history taken and the examination conducted. The doctor specifi cally records “safety net” advice given. This, and the precise note of the temperature taken, suggests that Mr T’s recall of the consultation may be fl awed.

The expert concludes that in hindsight it is clear Mr T was in the early stages of appendicitis on Day 2 and had he been referred to hospital at this point he would likely have avoided the subsequent complications. But it is also his view that Dr K provided a reasonable standard of care in his encounter with the patient.

MDDUS lawyers off er a firm rebuttal of the claim and it is eventually dropped.

Key points

• Good medical records are the best defence in negligence claims – especially with conflicting accounts.

• Comprehensive and contemporaneous notes will outweigh recall as evidence in almost every case.