Case study: Persistent swelling

BACKGROUND

Mr T is a 42-year-old IT technician and “occasional” smoker. He attends his GP, Dr K, complaining of a painful and swollen left testicle.

Dr K undertakes a history and examination and records: Left testicle, swelling and mild discomfort. No history of dysuria or pyrexia. No penile discharge. Examination: swelling, no mass, no tenderness, no sign of torsion. Urine dip negative for leucocytes, nitrates and blood.

A diagnosis of possible epididymo-orchitis is discussed and a prescription for a five-day course of antibiotics is provided. Mr T is told to return if the condition does not settle or worsens.

Mr T returns to the practice a week later still in pain. He says his symptoms seemed to improve but became worse again once he had finished the antibiotics. Dr K examines him again and notes: Left testicle firm, swollen and tender. No lumps, craggy areas. The GP prescribes a longer course of antibiotics and again advises Mr T to return if the pain and swelling does not ease or gets worse.

Two weeks later Mr T is back at the surgery. He states again that the pain seemed to ease at first but returned after the antibiotic course and he now worries it may be cancer. He also complains about a significant increase in the swelling. Dr K notes on examination: Left testicle persistent swelling, no discrete lumps or glands.

The GP reassures Mr T that it is likely just an infection and again records a diagnosis of epididymo-orchitis. He prescribes a further two-week course of antibiotics, advising Mr T to return for review if no better.

On completion of the antibiotics, Mr T contacts the surgery still complaining of pain and swelling. He is urged by his wife to get a second opinion and attends a different GP. An ultrasound scan is arranged. The results record a mixed echo heterogenous vascular mass suggestive of testicular neoplasm. Mr T later undergoes a left inguinal orchiectomy, and cellular pathology confirms a metastatic seminoma with para-aortic lymphadenopathy. He undertakes chemotherapy post surgery.

Solicitors acting for Mr T send a letter to the practice alleging clinical negligence. It claims that Dr K breached his duty of care in failing to refer the patient timeously for further investigation of his grossly swollen testicle. This led to a four-month delay in the diagnosis, with extensive pain and anxiety. Mr T now worries his prognosis is worse.

ANALYSIS/OUTCOME

MDDUS acting on behalf of Dr K commissions reports from an expert GP and a clinical oncologist.

The GP report addresses the allegation of breach of duty of care and concludes that persisting with antibiotic treatment over a month without further investigation to explain the cause of the pain and swelling would be difficult to defend in court.

The clinical oncologist comments on causation (consequences of the breach of duty of care). He concludes that Mr T’s treatment (surgery and chemotherapy with associated side-effects) was unaffected by the delay in diagnosis – nor is his prognosis with a predicted cure rate of over 95 per cent given the pathology and staging.

The expert does agree that the delay led to prolonged pain and anxiety, with Mr T and his family left to worry that the delay might have meant a worse prognosis.

MDDUS in agreement with Dr K negotiates a settlement in the case.

KEY POINTS

• Address patients’ ideas, concerns and expectations when consulting to ensure their needs are appropriately met.
• Consider potential differential diagnoses, with reference to published guidance, and safety net with the patient accordingly.
• Consider seeking an early second opinion when symptoms are not resolving as expected.