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Investigation of blood in urine missed diagnosis of rare heart tumour (00HDC06335)

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(00HDC06335, 24 May 2002)

General practitioner ~ Cardiology ~ Standard of care ~ Atrial myxoma ~ Missed diagnosis ~ Differential diagnosis ~ Investigations ~ Radiology ~ Right 4(1)

A female athlete in her forties complained that a GP she had consulted over five months did not listen or act upon her description of her symptoms or her concerns and failed to diagnose that she had an atrial myxoma. Following an initial consultation for an insurance medical check the only abnormality detected was haematuria (blood in the urine). Over subsequent consultations the woman complained of fatigue, breathing difficulties, and a general deterioration of health. These symptoms were ultimately found to be attributable to an atrial mxyoma. The Commissioner held that there was no breach of Right 4(1).

With regard to the haematuria, the GP arranged a renal ultrasound, renal function tests and an IVP (intravenous pyelogram), which were normal, and then proceeded to undertake further investigation including blood tests and urinary cultures, and consulted with two specialists - a nephrologist and a urologist. Although the right conclusion was not reached, the GP made an effort to ascertain a reason for the haematuria. It was held that the GP conducted appropriate examinations, tests and consultations to exclude serious pathology.

With regard to the patient's complaints of fatigue, tiredness is a non-specific symptom, which requires further investigation only if history, examination, and routine tests indicate significant disease.

The patient was concerned that her shortness of breath might be indicative of sarcoidosis, and complained that the GP dismissed her concerns without conducting appropriate tests to rule this out. Independent advice stated that ideally the patient's heart should have been auscultated when she presented with shortness of breath, but that the GP exercised reasonable care and skill. There was no reason to believe that the patient was presenting with sarcoidosis.

The GP did not breach the Code by failing to diagnose the atrial myxoma, an exceedingly rare condition. Although a cardiologist would have more knowledge and experience of the condition, it would be unreasonable to expect a GP to immediately diagnose the condition if it had not previously been encountered. The diagnosis of exercise-induced haematuria was considered appropriate; it was not clear that further investigation of the haematuria would have led to the correct diagnosis.

Overall the GP exercised appropriate care and skill, considering the difficulty of the diagnosis. It is all too easy to judge the GP's actions with the benefit of hindsight, but to do so would be onerous and unfair. The cluster of symptoms became meaningful only when the atrial mxyoma was detected.