The patient visited her GP five times in one month complaining of a recurrent tight chest. On examination, the GP noted that crepitations and wheezes were audible on auscultation.
He suspected that the patient had asthma and took peak flow readings, which were variable. He prescribed an inhaler and, one week after the patient started to use this, the GP noted that her condition had improved.
The GP did not see the patient again for eight months, when she returned complaining of a number of symptoms including sickness, diarrhoea, anorexia, nausea and itchy skin. The GP examined her and found no evidence of liver enlargement. He thought she had hepatitis A, and arranged liver function tests which appeared to confirm this. He monitored her condition during subsequent appointments and, after a blood test three months later, noted that her liver function had returned to normal.
A month after this however, the patient returned to the GP complaining of bronchial catarrh. The GP examined her chest and concluded that she did not have a chest infection.
He took a peak flow reading, which he noted to be 350/450, and advised the patient to use her inhaler regularly. When he saw her again three weeks later, her condition had improved.
The patient returned for three further appointments during the next two months. Her condition had worsened. At one appointment her peak flow was below 300. The GP noted that the patient had thrush and prescribed a non-steroid antibiotic preparation as an alternative to the steroid inhalers which she had been using. He also prescribed an expectorant.
The GP wrote to a consultant chest physician requesting a second opinion. Within days of this letter being sent as a non-urgent referral, the patient returned to her GP complaining of a lump in the left supraclavicular node. The GP then urgently referred the patient to hospital for a chest x-ray. The x-ray report said the most likely diagnosis was lymphoma.
The patient was admitted to hospital for lymph node biopsy, which led to a diagnosis of Hodgkins disease stage IVB.
The patient was treated with chemotherapy and radiotherapy and eventually recovered.
It was alleged that the GP ought initially to have diagnosed Hodgkins disease instead of asthma.
Several experts were consulted. All but one defended the GP's management. There was some dispute as to whether the patient had in fact suffered from asthma, though, according to one GP expert:
"...virtually every GP presented with this history, the findings on examination, the fluctuating peak flow results and the improvement after inhaled steroids would conclude that the patient was suffering from asthma".
This expert thought it was unlikely that the enlarged lymph glands would have been present if the GP had arranged for the patient to have a chest x-ray when she first visited him with wheeziness.
While weight loss was a symptom of Hodgkins disease, it had been reasonable at the time for the GP to attribute this to the hepatitis A infection. He concluded:
"According to a recent survey of 1034 cases by the Hodgkins Disease and Lymphoma Association, 78 per cent of them presented with 'lumps/swellings'. Only 115 had breathlessness. When it develops behind a common illness like asthma then diagnosis is extremely difficult until the glands become palpable".
The case was discontinued before it came to trial.
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