One of the essential skills of the ever-learning and practising general practitioner is the ability to pick up the signals. These signals will be flashed at any time on any day of any week amid a great variety of often mundane clinical material presented. They may happen frequently or infrequently, in singles or in runs; they have no respect for public holidays, Monday morning brain fog, or the Friday afternoon dreamtime, and they have no respect for the time of day … as these authentic case histories show.
‘Doctor, could you come to see Albert? He’s rolling about and says the pain in his tummy is terrible.’ It was just at the end of evening surgery and everything had seemed tidily tied up.
I set off, mentally rehearsing the patient’s history as I drove the short distance to his home: committee man, ardent Mason, keen Rotarian—background of cigarette emphysema, two years ago had a RIND (resolving ischaemic neurological defect), known chronic duodenal ulcer (on cimetidine) and secret whisky imbiber.
When I arrived he was rolling about and looked dreadful. The onset had been sudden as he was about to go to a Rotary dinner and he was obviously not suffering a perforation. He was tender throughout and bowel sounds were numerous.
The betting was between bowel obstruction and pancreatitis. A phone call to our usual surgeon resulted in admission, and confident, conservative management of a likely pancreatitis was expected. Then a sudden change of tack was called for. His condition deteriorated and urgent laparotomy revealed a large section of gangrenous small bowel tucked in a corner—an unexpected outcome.
During that same evening surgery our Family Medicine Programme (FMP) trainee had asked me to look at a man with a unilateral leg swelling and associated peculiar rash. Sure enough, this man in his early 30s had a pale, swollen leg with some bruising. His own doctor a few days earlier had diagnosed a simple injury, yet there had been no trauma and beside the ‘bruising’ there were a few small purpuric spots—the ‘telltale’ spots.
Next morning the haematologist phoned to confirm a ‘hairy cell’ leukaemia.
‘We’ll start him on interferon—the drug that has been looking for a disease for years. At last it has found one.’
Our FMP trainee had gone numb thinking about the implications of the diagnosis. The week before we had seen an 8-month-old boy with ‘bruising’. A few days before, he too had been seen by another doctor who, after careful examination, had concluded that it must be simple trauma. Blood examination had revealed a dangerously low platelet count.
Diagnosis always seems easy the second time around.
Mr B had complained of a change in his bowel habit. He had done this before and investigation had been negative. Nonetheless, one must always abide by the rules, and so barium enema was performed and no neoplastic lesion identified; all seemed well.
Later Mr B came to see my partner. He now had pain in his lower abdomen and his social life had been wrecked because he now always felt ‘ready to go’. Sigmoidoscopy was performed, and a large lesion was identified in the sigmoid colon and resected. Reporting back to base with an additional clue saved his life.
Wilhelm, an ageing Dutchman, had told me of the spots he could see before his right eye. Vision seemed fair on my examination—‘floaters’ seemed a reasonable answer.
Luckily, GPs (like Agatha Christie’s Hercule Poirot) develop ‘the nose’, and a hunch that something was not quite right pushed me to phone our favourite ophthalmologist. A small retinal tear was identified and repaired that same night.
DISCUSSION AND LESSONS LEARNED
During our weekly discussion it was pointed out to our FMP trainee that in general practice one must never develop the ‘Dr Kildare syndrome’. Problems do not come one at a time, to be solved once a week in episodic fashion. They attack from all angles at the same time; each one has to be resolved and they have to be resolved in parallel. Having dealt with one problem the GP has then to go out and ‘face the next ball’.
General practice may be compared to a complex game. There are problems to be solved and approaches can vary. The answer may be in a spot diagnosis or perhaps logical steps. You may get a second chance, especially when provided with an additional clue. It may be that a hunch or second thoughts set you on the right track, or you may be lucky enough to take advantage of an opponent who has missed the vital clue on first confrontation, and, of course, the answer and solution may be totally unexpected. Complex indeed—general practice is not easy.