Just a tummy bug? - medical case study

...Entering the consulting room Sam grows extremely distressed, crying hysterically and clinging to his mother. Nothing will calm him and eventually Dr J gives up trying to examine the boy...

BACKGROUND: A mother attends an emergency appointment at the GP surgery with her four-year-old son Sam. The child had seen his regular GP two days before with vomiting and abdominal pain and was diagnosed with viral gastroenteritis. Sam’s mother was advised that the condition would soon run its course but in the past 24 hours the boy’s symptoms have not improved.

Sam is seen by another GP – Dr J. Upon entering the consulting room the boy grows extremely distressed, crying hysterically and clinging to his mother. She explains that Sam is afraid of doctors. Nothing will calm him and eventually Dr J gives up trying to examine the boy, though he does manage to determine by touch that Sam is not feverish.

The boy’s grandmother is in the waiting room and Dr J suggests Sam wait with her so that he can discuss the boy’s condition with his mother. Dr J observes Sam jump into his grandmother’s lap with no obvious signs of pain or tenderness. In the consulting room alone with Sam’s mother Dr J suggests the boy is still suffering from viral gastroenteritis and explains the importance of keeping him hydrated and treating any fever with paracetamol.

Two days later Jack attends the local A&E with extreme abdominal pain. Examination suggests a possible appendicitis and this is confirmed upon surgery. Sam spends four days in hospital recovering from the appendectomy along with an associated infection. One month later the practice receives an angry letter of complaint from Sam’s mother.

ANALYSIS/OUTCOME: In the letter of complaint Sam’s mother alleges that Dr J failed to properly examine the boy and dismissed her concerns that he might be suffering with something more serious than a "tummy bug". As a result Sam suffered for an additional two days before being diagnosed and undergoing surgery.

The practice manager contacts MDDUS and forwards the letter of complaint along with a draft response from Dr J. In his response the GP states that when Sam came into the consulting room he was distressed and an adequate examination was very difficult. Even if the examination had been forced it would not have been possible to adequately assess the child for tenderness as the abdominal muscles were tensed with stress.

He states that in his experience children with acute appendicitis tend to lie still with the legs drawn up. In observing Sam wriggling about and climbing into his grandmother’s lap he concluded that it was unlikely to be a serious problem – but he did advise the boy’s mother to bring him back to the surgery if his condition did not improve.

An MDDUS adviser assists Dr J in drafting a letter of response to Sam’s mother. The GP expresses his sincere regret in Sam’s additional suffering but explains the difficulty sometimes in diagnosing appendicitis, especially in a distressed child. The GP states further that since receiving the letter he has reviewed his understanding of the presenting features of appendicitis and his approach in examining distressed children. He offers to meet with the family to discuss the matter further.

Sam’s family respond to say they are satisfied with the GP’s explanation and the case is closed.

KEY POINTS

  • Have a high index of suspicion in symptoms persisting beyond the normal course of a viral infection.
  • Develop strategies for coping with distressed children – for example using distractions such as toys or rewards or allowing time for the child to calm down before attempting the examination later.
  • Explain clearly to the parents the limitations of the consultation and advise an early return if the symptoms don’t improve.

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