Mystery abdominal pain

A man in his 30’s attended his GP complaining of pain in the lower abdomen which had begun that morning. There was no associated nausea or vomiting.

The GP noted that she carried out a full examination of all areas of the patient's abdomen, first by superficial palpation and then by careful deep palpation, including testing for rebound tenderness. There was no rigidity or guarding, although the GP noted that there was mild tenderness in the hypogastrium.

A rectal examination was unremarkable and the pulse was normal at 80 beats per minute. There were no urinary problems. The patient was advised that the pain could be related to an irritable bowel, or constipation – which the patient said he had experienced that morning. The GP prescribed a laxative and advised the patient to seek medical advice immediately if the symptoms worsened.

A week later the patient returned and was seen by a different GP. The patient told this GP he was still in pain, and also complained of night sweats, light-headedness and weakness. On examination the GP noted the patient's abdomen was tender in the right iliac fossa.

The second GP suspected appendicitis and referred the patient to hospital that day, the referral letter stated that the pain had been present for one week. The patient underwent an appendicectomy and a colostomy. The hospital records showed that the patient was eventually diagnosed with acute diverticulitis that had perforated into his appendix. The colostomy was later reversed.
A year later, the first GP, an MDU member, received a solicitor's letter claiming that she had failed to carry out a proper physical examination and as a result had negligently missed a diagnosis of appendicitis. The letter claimed that, had the correct diagnosis been made at that stage, a simple appendicectomy could have been performed laparoscopically and the colostomy avoided. The patient was claiming damages for pain and suffering, loss of earnings and the cost of care and assistance. The member contacted the MDU for help.
The MDU obtained the opinion of a GP expert who advised that the notes showed that the member's assessment of the patient was 'very thorough' and included an appropriate physical assessment, including careful examination of all quadrants of the abdomen and noting that there was no rigidity or guarding.

The expert also commented that acute appendicitis is often associated with a raised temperature and tachycardia, neither of which had been present. He concluded that given the full history obtained by the GP, and the absence of signs suggestive of appendicitis, diverticulitis or peritonitis, her suggestion that the pain might be due to constipation or an irritable bowel was perfectly reasonable. In his view, the GP had acted responsibly by advising the patient to return if his condition worsened and that surgery may well have been less complicated if the patient had returned earlier.

The outcome

In the light of this report, the MDU provided a detailed response to the patient's solicitors, denying the allegations made against the GP. This letter of response made it clear that a GP expert had advised that a reasonable body of competent GPs would have managed the case in the same way as our member had done.

The MDU stated that the examination had been appropriate, including a test for rebound tenderness, and that it was improbable that there were any signs of appendicitis at this time.

The claim was eventually discontinued.

This page was correct at publication on 22/12/2010. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.