Missed diagnosis

This month’s clinical scenario is one which trainer’s fear happening to them and trainee’s need to feel won’t happen in order to trust their trainer.
Missed diagnosis
You are working as an ST3 in general practice and your trainer has asked you to discuss your referrals with him or other senior colleagues. You see a 61-year-old lady in surgery who is very concerned about a pigmented lesion on her back. You share her concern about the lesion and decide to refer her to the local dermatology clinic through the two-week wait pathway. You ask your trainer to review the lesion and to confirm the management plan. Your trainer dismisses your concerns and feels that the lesion is a seborrhoeic keratosis and proceeds to reassure the patient that a referral is not necessary. Several weeks later the patient returns to see a different GP at the practice and is referred to the local dermatology clinic where the diagnosis of malignant melanoma is subsequently confirmed. You read the clinic letter and are very upset to learn about the diagnosis.
 
Suggested points for discussion:

  • Who would you talk to in the practice about this experience?
  • How might you discuss this with you GP trainer?
  • Where does the responsibility lie for the initial decision not to refer?

 

Link to RCGP Forums: InnovAiT Clinical Scenarios course within the OLE:
Link to latest (July 2018) forum discussion within the OLE:
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Fictitious Illness

neurological
This month’s Clinical Scenario is shown below and available for your comment.
I am not sure that I can recall a patient of mine in exactly this scenario, but certainly very similar and for them it was the need for a diagnosis which I think motivated the assertions. Or perhaps I was being naive and there was in fact a drug seeking intent also. It is a difficult path we must take as GPs. We are taught to ask for patients’ ideas, concerns and expectations of the situation and to trust what the patient is telling us. If we always second guess and think we know better than the patient we will have a miserable time in practice. However there is a need to hold cynicism in our mind too. I remember one of my more senior consultants from medical school who listened patiently but questioned everything he was told, selecting only a few nuggets of information to take as truth. He would now perhaps struggle with recognised expectations of communication skills but he was a great diagnostician to observe!
Fictitious illness
A 48-year-old lady comes in to see you for the first time. At the first meeting you have no past notes. She tells you that she has longstanding rheumatoid arthritis (RA) however, you think it is odd that the patient appears to be completely fit and active, has no regular medication and cannot give you details of the consultant responsible for her care. When the notes finally arrive at the practice you cannot find any record of a diagnosis of RA. The next time she comes in you challenge her about this and she says that the diagnosis was suspected but never proven however, she firmly believes that she does have RA. Therefore, you repeat her autoimmune profile and inflammatory markers which all come back normal.
Suggested points for discussion:

 

  • What reasons might this woman have for claiming that she has RA?
  • How might you manage this situation?

 

Link to RCGP Forums: InnovAiT Clinical Scenarios course within the OLE:
Link to latest (May 2018) forum discussion within the OLE:
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Which vaccination reduces incidence of acute otitis media?

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If you have anything ENT listed on your PDP then it is worth having a look at OnlineFirst to see the most recently published articles.

Neck lumps has just been added to the essentials Acute otitis media and Otitis externa.
There are articles on Hoarseness and Head and neck cancers discussing how they present and how we can best avoid the delayed diagnoses often associated.

The article on the very rare but not to be missed diagnosis of Acute supraglottitis focuses on the presentation in adults as the more traditionally taught drooling child is fortunately much less common.

Finally, although not ENT, there is an excellent discussion regarding Dental emergencies in primary care. This is a well versed issue so having clear advice is very welcome.

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Supervision and staffing

Recent events which have been well documented in the press and all over social media, make this an especially poignant scenario. As a junior doctor I was used to firefighting and doing the best I could. There was a team camaraderie so on the tough days everyone supported each other but was this gold standard, well supervised care? Possibly not. These recent cases and the change in doctor-patient dynamics with more litigation and complaints, have moulded me into a more defensive practitioner. Perhaps I should in fact welcome this. If, after all, I am following all the guidelines and protocols, referring freely, am I now providing gold standard care?
Here is the Case scenario for your perusal and please do add your comments on the links below:

You are an ST3 GP registrar working in a small rural practice with two full time GP partners and a salaried GP. Every Friday you help the salaried GP with the ‘on call’, which includes telephone triage in the morning and an emergency ‘sit and wait’ surgery in the afternoon, as well as helping to supervise an F2 doctor and nurse practitioner. You are prepared for a busy day as one GP partner is on holiday and the other does not work on Fridays. However, when you arrive at work the practice manager informs you that the salaried doctor has gastroenteritis and has called in sick.

The practice is unable to find a locum GP at such short notice and the GP partner who is not on holiday is not answering his phone. The experienced nurse practitioner is anxious and suggests the remaining staff should not see patients without supervision from a senior GP and feels the surgery should close for the day. The practice manager asks you if you would do the ‘on call’ alone and supervise the nurse and F2 doctor.

 

Suggested points for discussion:

 

  • What would you do in this situation?
  • Who else could you ask for advice or help?
  • What would you do if there was a particularly ill patient requiring attention?
  • What would be the medical indemnity perspective?
  • What other options does the practice have in this situation?

 

 

 

Link to RCGP Forums: InnovAiT Clinical Scenarios course within the OLE:

http://elearning.rcgp.org.uk/course/view.php?id=219

 

Link to latest (February 2018) forum discussion within the OLE:

http://elearning.rcgp.org.uk/mod/pageplus/view.php?id=8081

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Thinking of antiphospholipid syndrome in infertility and miscarriage

contraception (3)

This is the second blog from Professor Graham Hughes of the London Lupus Centre.

Earlier this month, I took part in the 20th ‘Ten Topics in Rheumatology’ meeting in Barcelona.  Over these past 2 decades, the ‘Ten Topics London’ and ‘Ten Topics Barcelona’ meetings have nourished a very strong link between our unit at St Thomas’ Hospital (and now at London Bridge Hospital) and a number of medical and research centres in Spain.

This meeting was no exception – for me, a catch-up with old friends, and with recent advances, notably in lupus and Hughes Syndrome.

One of the highlights of the meeting (at least for me), was a presentation by a Spanish doctor, Dr Silvia Fontdevila, on the impact of the newer antiphospholipid tests now coming on stream.

Although not yet in widespread use, the tests hint at the exciting prospect that one day soon, they will replace the capricious and wrongly named “lupus anticoagulant” test.

Here’s hoping!

My own talk at this year’s meeting was entitled “Hughes Syndrome/APS – 34 years on and counting”.

I chose ten ‘topics’ which, for me, still pose both challenges and questions in the world of Hughes Syndrome. The topics I chose were:

  1. Hughes Syndrome and sleep disturbance (?under recognised)
  2. Migraine (Hughes Syndrome/APS – a link with stroke?
  3. Genetics of Hughes Syndrome (the importance of the family history)
  4. Multiple sclerosis (how many cases are APS?)
  5. “Funny turns” (epilepsy – an important feature of Hughes Syndrome)
  6. Fainting in school (sometimes a link with POTS)
  7. Problems with aPL tests (to be discussed in a future blog)
  8. Fractures and joint pains
  9. The impact on lupus (many of the features of lupus – recurrent miscarriage, stroke to name but two, are in fact down to APS rather than lupus itself
  10. The role of Hughes Syndrome in the problem of infertility

I will touch on all Ten Topics in future blogs but this month I focus on Topic 10 – infertility.

Patient of the Month

Mrs D.S. now aged 30, had a past history of ‘glandular fever’.  She also suffered from intermittent fatigue and frequent headaches.  No firm diagnosis was made.

At the age of 20, she married and planned for pregnancy.  However, no success. Between the ages of 21 – 24 she failed to become pregnant.

At the age of 24, a smart physician tested Mrs D.S. for antiphospholipid antibodies.  Result : highly positive. She was started on aspirin with clear improvement in her troublesome headaches – but, as yet, no positive pregnancy test.

Her doctor and an I.V.F. obstetrician conferred.  They took the pro-active (and brave) decision with Mrs D.S. and her husband to add in a trial of low molecular heparin.  Within one cycle, Mrs D.S. became pregnant. She maintained on both aspirin and heparin throughout a successful pregnancy.

What is this patient teaching us?

I believe that Ms D.S’s case raises the question:  “Is Hughes Syndrome under-recognised in infertility?

In the 35 years (and counting) since we reported the antiphospholipid syndrome, one of the biggest success stories has been in obstetrics, where the pregnancy success rate in women with recurrent miscarriage has risen from under 20% to over 90%.

The story in infertility is a lot more hazy.  Certainly in clinical practice, I see a considerable number of patients such as Ms D.S., whose history includes “infertility”.  Anecdotally, a number of I.V.F. specialists have tried adding aspirin and even heparin to their mix of treatments, but there is no definitive data out there.

Interestingly, there is a little laboratory mouse that develops APS, and work done by my late colleague, Dr Aziz Gharavi, showed that one of the clinical features of the ‘mouse model’ APS was, in fact, infertility.

Professor Khamashta, who was present in my Barcelona lecture, declared, in his forthright way, that the lack of studies on Hughes Syndrome in women with various patterns of infertility was unfortunate.  Certainly histories such as that of Mrs D.S., however anecdotal, should encourage such studies.

What is holding us up?  Firstly, ‘infertility’ has obviously a variable time-line.  And, as with so many features of Hughes Syndrome, the syndrome is almost certainly a cause, but one cause among many.

As in the case of recurrent pregnancy loss, rather than simply adding, say, heparin to the medicines given out in I.V.F. treatment, it may be productive to focus down on possible ‘at risk’ groups.  For example – there is a family history of ‘infertility’ (or even delayed conception), or of autoimmune disease such as thyroid, or of thrombosis?

There is such a need for a fresh focus on this important, and emotive problem.

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Rheumatology Case Study

We are very fortunate to have Professor Graham Hughes from the London Lupus Centre contributing to InnovAiT. He agreed for us to share his blog with our readers. Here is the first discussing a rare rheumatology case. Although we may not see many patients follow this same path, it is an opportunity to remember to think outside the box, and if something doesn’t seem quite right, to discuss with colleagues.

Interpreter

Case Study

EJ, an American physician in her forties, decided to come over to London for a second opinion at the London Lupus Centre.  She had been diagnosed in her home city of Boston as having Hughes Syndrome/Anti Phospholipid Syndrome (APS).

Her previous history was very significant.  In her teens, she had suffered attacks of fainting – especially in school assemblies.  She had also suffered from frequent headaches, as well as one seizure at the age of 15.  Investigations were initially non-diagnostic, though one brain scan (EEG) did suggest mild temporal lobe epilepsy.  She had also suffered a variety of joint pains, put down to her “double-jointedness”.

Despite all this, she succeeded at school and college, and graduated in medicine in her home town, Boston.

In her mid-30’s, however, she suffered what she described as a ‘perfect storm’.  Possibly following a ‘virus infection’, she became extremely unwell, with cough, chest pains, leg thrombosis, severe headache and T.I.A’s.  Over the course of 3-4 days, she became unconscious and was treated in the Intensive Care Unit at Boston City Hospital.

At this time, blood tests revealed a low platelet count and strongly positive antiphospholipid antibody tests.

Treatment in ITU included antibiotics, anticoagulants, platelet transfusions, as well as intravenous immunoglobulins and plasma exchange.

She survived and slowly returned to medical life.  Her medication was gradually reduced to warfarin.

However, for the past 3-4 years, she has continued to suffer occasional migraine headaches, as well as very unsettling ‘temporal lobe’ attacks, including episodes of ‘absences’ and ‘déjà vu’.  Fortunately these didn’t interrupt her career as a physician.

She had family in London and decided to combine a family visit with a ‘second opinion’.

Clinically she was doing reasonably well.  The diagnosis of Hughes Syndrome was confirmed and there was no evidence of lupus.  Her medication was fairly simple –anticoagulation with warfarin. Perhaps surprisingly, there was no medicine being taken for the temporal lobe symptoms.

But there was one striking anomaly.  Her INR readings (‘blood thickness’) were surprisingly low – printed out computer style (not the little yellow notebooks we know and love in the U.K.)…….3.1…..3.4…..2.9…..2.9…..3.2…..and so on.

Questioned about this later, EJ admitted that she had been concerned about the risks of bleeding (especially brain bleeds) associated with a higher INR.

This story has a happy – and interesting – outcome.  She returned to Boston, slightly raising the warfarin dosage, and with the added help of a self-testing INR machine.  We keep in touch. She is stable with an INR around 3.8 – 4. And interestingly, the headaches and ‘temporal lobe seizures’ have disappeared.

What is this patient teaching us?

At least 4 lessons:

  • Possible association with ‘POTS’.  

Since we reported a series of Hughes Syndrome patients with ‘autonomic nerve problems, including POTS (paroxysmal orthostatic tachycardia syndrome) – or more simply fast heart-rate and fainting on standing up.

We are also beginning to see more cases with the combination.  To further complicate the picture, a small number of these patients have a tendency to ‘hypermobility’ or double-jointedness.  More on this in a future blog!

  • ‘Catastrophic APS’

Dr EJ had suffered a life-threatening episode in which many organs ‘closed down’.  The death rate is up to 50%. In EJ’s case, recovery was complete, probably because of the quality of the intensive care treatment in Boston.

Because the condition is so rare, guidance regarding the best treatment is limited.  To overcome this, my colleague, Professor Ricard Cevera in Barcelona has introduced a central registry, aiming to pool international data – an outstanding contribution to our syndrome.

  • Epilepsy

In the 35 years since the description of APS, epilepsy has become one of the big stories of the syndrome.  Although the tendency to seizures was included in the original descriptions, recent reviews have reported that up to 1 in 5 cases of ‘idiopathic’ (no known cause) teenage epilepsy cases are aPL positive.

And not just ‘seizures’ but a variety of other types of epilepsy – notably temporal lobe epilepsy, as in Dr Elizabeth’s case.

And very significantly, the epilepsy can (and often does) respond to anticoagulation.  Again if evidence were needed of the importance of brain features in Hughes Syndrome.

  • Warfarin treatment

How common is the finding of an inadequate warfarin dose (for example, with an INR under 3), the clear reason for apparent treatment failure in Hughes Syndrome?

Such an important lesson!

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Doubling up

The next instalment of the clinical scenarios is now available. It’s certainly a very common occurrence and adds pressure onto any surgery. How do you manage this?

Doubling up

A patient well known to you with multiple health problems has recently got married. Her new husband registers with your practice. He also has multiple real health problems. Every time the wife comes to see you, the husband brings up his own health problems and wants to discuss them with you. He always states that his problems are urgent but never makes his own appointment. You have asked him several times to make an appointment for himself rather than discuss his problems in his wife’s appointment but this behaviour is persisting. They are frequent visitors to the surgery and always make you run late.

Suggested points for discussion:

  • Is it appropriate for the husband to discuss his own health problems in his wife’s appointments?
  • How might you manage this situation?

Link to RCGP Forums: InnovAiT Clinical Scenarios course within the OLE:

http://elearning.rcgp.org.uk/course/view.php?id=219

Link to latest (February 2018) forum discussion within the OLE:

http://elearning.rcgp.org.uk/mod/pageplus/view.php?id=7996

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Prescribing and prescription charges.

This month’s clinical scenario is now available for you to consider regarding a situation which I have definitely experienced. Also with regards to mebendazole for treatment of worms in families. Following these, I have fairly clear plans for how I now manage such situations but look forward to seeing if mine are similar to yours.

Prescribing and prescription charges
You are a GP working in an inner city practice in an area of significant socio-economic deprivation. You see a mother and 3-year-old son who has an itchy rash all over his body. The rash is in his finger creases as well as all over his abdomen. You suspect a diagnosis of scabies and treat with permethrin. You recommend treating the rest of the family which on further questioning consists of mother and father, two older siblings aged 17 and 18 years and the patients grandmother who is 59 years old and lives with them.
When explaining the need to treat the whole family to the patients mother, she asks you to prescribe all the treatment in the child’s name as the mother wishes to avoid paying the prescription charge. When you explain you cannot do this, the patient’s mother becomes angry, threatens to complain and states that the rest of the family will go untreated unless you prescribe as she requests.
Suggested points for discussion:
  • What would you do in this situation?
  • Is it legal to do as the patient’s mother asks?
  • Do you have a duty of care to ensure the other family members are treated?
  • What other options are available to help the patient’s family?
Link to RCGP Forums: InnovAiT Clinical Scenarios course within the OLE:
Link to latest (February 2018) forum discussion within the OLE:
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Gifts; more trouble than they’re worth?

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Having just had Christmas, I would be fibbing if I didn’t look forward to the odd box of chocolates and bottle of wine from a patient. Although I am aware that I probably received more as a trainee than I do now! I am blaming this on working fewer clinical sessions now, but I am also aware that I don’t have as much time to give to patients. However, should I assess my value as a good GP on the number of Christmas gifts I receive? Probably not.
The scenario below however, is a little more than a box of chocolates. I think I would feel very awkward, but see what you think….and don’t forget to add your comments.
Practice donations
A very grateful patient comes in to see you following a successful procedure to remove an early bowel cancer that you detected. As he gets up to leave, he thrusts a thank you card into your hand. When you open it after he has left, you find £400 in cash enclosed in the card.
Suggested points for discussion:
  • Are there any rules about accepting patient gifts?

 

  • How might you manage this situation?

 

Link to RCGP Forums: InnovAiT Clinical Scenarios course within the OLE:
Link to latest (December 2017) forum discussion within the OLE:
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Prostate cancer screening. Clinical scenario

This month’s clinical scenario is now available for discussion. This can be included with your reflection to your portfolio/CPD and you can see what others have commented on previously.
Prostate cancer screening
 
An 89-year-old man comes in to see you to ask for a prostate specific antigen (PSA) test. He is very fit and well for his age and has no urinary symptoms. He asks you why there is no national prostate cancer screening programme when there is a breast cancer screening programme. He recently watched a television programme which had concluded that thousands of men’s lives could be saved if there was a national screening programme. He thinks the lack of a screening programme is very sexist.
 
Suggested points for discussion:

 

  • Is it true that thousands of men’s lives could be saved if there was a national prostate cancer screening programme?
  • What are the possible harms that could be caused by PSA screening?
  • If you were this man, would you ask for a routine PSA test?

 

Link to RCGP Forums: InnovAiT Clinical Scenarios course within the OLE:
 
Link to latest (December 2017) forum discussion within the OLE:
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