Gut pain

BACKGROUND

Ms R attends A&E one evening having suffered a sharp abdominal pain when getting out of her car.

An emergency medicine registrar examines Ms R and takes bloods, and she is placed on a drip and administered analgesia. An ECG is ordered and she is later examined by a surgeon and discharged home with a diagnosis of abdominal muscle strain.

Three days later Ms R attends her GP surgery still suffering from abdominal pain. She is seen by Dr C, who records a history of vomiting and constipation in the previous 48 hours, though much improved now. Ms R reports drinking to excess "on occasion" and she is also a smoker. Examination reveals the patient is afebrile with local tenderness in the right side of the abdomen.

Dr C records a diagnosis of muscle sprain and advises Ms R to take regular paracetamol and return for follow-up in a week if there is no improvement.

Test results from the patient's earlier hospital attendance are received by the practice and reveal a slightly raised white blood cell count and C-reactive protein (CRP). Liver function tests and renal function are normal. Dr C reviews the blood tests and asks a colleague to phone Ms R and advise that she may have a urinary tract infection. She is asked to collect a prescription for antibiotics.

A week later Ms R is back in the surgery with persistent abdominal pain. Examination again reveals a tender right side of the abdomen and potential hepatomegaly. Dr C arranges an urgent abdominal ultrasound scan and blood tests for calcium (bone profile), vitamin B12 and folate, CRP, electrolytes and creatinine, full blood count, ferritin, HbA1c, liver function tests and thyroid function tests.

Two days later Ms R is driven to hospital by her partner with sudden-onset right-sided abdominal pain and vomiting. She is diagnosed as having appendicitis with perforation and multiple collections. She undergoes an emergency appendicectomy and intra-abdominal washout.

Ms R endures an extended recovery on IV antibiotics and is discharged from hospital over two weeks later.

A letter of claim is later received by Dr C alleging clinical negligence in his care of Ms R. In particular it is claimed that Dr C neglected to adequately examine Ms R given the presenting symptoms of suspected appendicitis. It is also alleged that Dr C diagnosed UTI without evidence, symptoms or urinalysis, and that Ms R should have been referred back to hospital for more tests given her persistent symptoms.

It is claimed that the failure to refer resulted in a ruptured appendix and emergency surgery, with peritoneal infection and a prolonged recovery.

ANALYSIS/OUTCOME

An MDDUS adviser reviews the case and a primary care expert is instructed to provide an opinion.

Upon reviewing the case notes, the expert concludes that Dr C's examination of Ms R at the first consultation was adequate and reasonable. He excluded a raised temperature and dehydration, and performed an abdominal examination to assess whether there was indication of acute appendicitis at that time.

The expert goes on to say that it was reasonable, in view of Ms R’s symptoms and the blood tests in hospital revealing a raised white cell count and raised CRP, for Dr C to provide empirical treatment with regard to antibiotics for the possibility of a UTI before reviewing Ms R in surgery the following week.

The expert notes that Dr C examined the patient at the second consultation (including per rectum) and again reasonably excluded an acute abdominal condition. He arranged blood tests and an ultrasound scan in order to consider the need for further assessment, investigations or specialist referral, in particular with the possibility of an enlarged liver.

A letter of response is drafted by an MDDUS lawyer on behalf of Dr C denying breach of duty and causation (consequences of that breach) – and thus liability. Nothing further is heard from the solicitors acting for Ms R and the case file is closed.