A 41-year-old estate agent, Mrs P, attended the emergency department by ambulance complaining of pain to her upper chest and left shoulder, which had started the same day. On examination, her chest was clear and ECG and temperature were normal, and she was discharged with a diagnosis of muscle spasm.
She presented to her GP, Dr N, three days later complaining of ongoing pain to her upper back, chest and both shoulders. Dr N recorded that Mrs P said her chest hurt when she breathed and she felt tired. Dr N was aware of Mrs P’s attendance to the emergency department, and in his consultation sought to establish if there was an alternative, perhaps more serious, diagnosis than muscle spasm.
On examination, Mrs P had a respiratory rate of 16 breaths per minute, normal auscultation of the chest, and an oxygen saturation of 98%. She was tender on palpation of her upper back, chest and shoulders. Dr N did not check Mrs P’s temperature and she did not complain of feeling feverish. Following a thorough history and examination, Dr N concurred with the emergency department’s diagnosis of muscular pain, and prescribed analgesia. He advised Mrs P to return if there was no improvement within a couple of days, or to return urgently or attend the emergency department if she felt matters were deteriorating.
Mrs P contacted the practice again two days later, this time speaking to Dr R, to say she felt no better and now also had a cough. Dr R arranged a home visit and found Mrs P to be very short of breath at rest, with a heart rate of 120 beats per minute, a respiratory rate of 26 breaths per minute, and oxygen saturation of 93%. Coarse crackles were heard bilaterally on examination of the chest.
Dr R was concerned that Mrs P may be suffering from pneumonia, and arranged hospital admission. Shortly after arriving at hospital, Mrs P deteriorated and required intubation and ventilation, with admission to intensive care. Microbiology investigations were positive for Streptococcus pneumoniae.
Mrs P remained in intensive care for ten days, and was discharged from hospital a month after she was originally admitted.
A claim was brought against Dr N, alleging that he negligently failed to perform a proper clinical examination, to include temperature measurement, and failed to exclude pneumonia as a diagnosis. It was further claimed that at the time of the consultation with Dr N, Mrs P had been unable to walk without assistance and was struggling to breathe.
It was alleged that antibiotics should have been commenced and/or referral to hospital for further investigation should have taken place, and had this been done Mrs P’s lengthy hospital admission would have been avoided, and she would not now be suffering from ongoing fatigue that prevented her from returning to work.
Expert opinion
Medical Protection instructed a GP expert and a respiratory medicine expert.
The GP expert considered that although there was a factual dispute about how unwell Mrs P appeared to be at the time of the consultation with Dr N, the medical records demonstrated no evidence that there were clinical signs of pneumonia, and there was no requirement for Dr N to have prescribed antibiotics or made a referral to hospital in view of the normal respiratory rate, normal oxygen saturation and no abnormal chest signs on auscultation. The muscle tenderness elicited on palpation would not be consistent with pneumonia and would not necessitate antibiotic treatment. The GP expert concluded that Dr N’s management was appropriate and of the standard of a responsible body of GPs.
The respiratory medicine expert considered that, on balance, even had Mrs P’s temperature been taken by Dr N, this likely would have been normal in the absence of any description of fever by Mrs P and the fact that a normal temperature was recorded on her admission to hospital. Had Dr N referred Mrs P to hospital and a chest x-ray obtained, this is likely to have shown features of pneumonia. Had broad spectrum oral antibiotics been commenced by Dr N or by the hospital, then it is likely progression to severe pneumonia would have been prevented, thus avoiding the need for hospital admission and intensive care. Complete recovery would have been achieved after approximately six weeks.
On the basis of the medical records, the evidence of Dr N and the views of the experts, especially that of the GP expert, Medical Protection defended Dr N’s actions and the claim subsequently discontinued.
Learning points
- Do not assume that a diagnosis made by a previous clinician is always accurate – consider alternatives and seek to establish if there could be serious or sinister causes for symptoms.
- Good clinical record keeping is vital, including documentation of observations. In the context of a claim, a factual dispute between the claimant and the clinician may arise, and thorough notes help to prevent or resolve such issues.
- It is important to provide safety netting, including advising a patient to return if there is no improvement within a specified time frame, as well as advising on action to take if symptoms deteriorate.
- In New Zealand, this scenario might have been considered by ACC as a treatment injury (delay in diagnosis) or by the HDC as a complaint. The key question to consider is whether the management was reasonable, given the history, symptoms and signs at the time of Dr N’s assessment. There was no history of cough or fever, but she did have pain on breathing and felt tired. Dr N clearly considered chest pathology as a possibility, and recorded respiratory rate, oxygen saturations and listened to the chest. These were all normal. In addition, she had muscle tenderness consistent with muscular pain. The GP expert’s assessment is consistent with the facts. The respiratory medicine expert’s opinion contains conjecture that is not relevant to the question of whether the management was reasonable.