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Missed diagnosis of pneumonia in patient with dark bowel motions (00HDC05800)

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(00HDC05800, 2 July 2002)

General practitioner ~ Specialist physician ~ Registrar ~ House surgeon ~ Public hospital ~ Elder care ~ Standard of care ~ Atypical presentation of pneumonia ~ Myocardial infarction ~ Missed diagnosis ~ Record-keeping ~ Right 4(1)

A 75-year-old woman became unwell and consulted two GPs. When she was admitted to hospital she had pneumonia. While in Intensive Care her respiratory failure was complicated by an acute myocardial infarction and she died. The woman had consulted the first GP with symptoms of nausea, aching muscles, headaches, tiredness, and a lack of appetite for a period of five days. The GP's history and examination were considered of an acceptable standard, and the presumptive diagnosis of a viral illness was reasonable. Even if the patient already had pneumonia, it is difficult to diagnose in its early stages, and the GP did all that could reasonably be expected.

The patient returned to the medical centre three days later and saw a GP she had not previously met. She had deteriorated, was very weak, and had been passing dark bowel motions. The GP checked her blood pressure, pulse and chest, examined her abdomen, and performed a rectal examination, which revealed her motions to be light brown. It cannot be known whether she had pneumonia at this time. Independent advice stated that the GP should also have taken her temperature and recorded more of his questioning. A second presentation of an unwell and weakened patient warranted a more detailed history and examination. The GP's role at this point was not to make the diagnosis of pneumonia (which would have been difficult given the atypical presentation), but to judge the degree of her unwellness and decide between the appropriateness of hospital or home care. The Commissioner held that the GP breached Right 4(1) by failing to obtain sufficient information to reach an appropriate decision.

The patient subsequently collapsed at home and was taken by ambulance to hospital. On arrival the house surgeon recorded the woman's recent symptoms and medical history, retrieved her old medical notes, took blood samples, organised a chest X-ray and presented her to the registrar for review. The house surgeon appropriately assessed the patient, and his interventions were timely and appropriate. There was no indication that urgent admission to Intensive Care was required. The registrar completed a full assessment and reviewed the chest X-ray, which showed "white out" of the lung. An ultrasound was performed and intravenous antibiotics administered. The registrar discussed the patient with the physician and the Intensive Care registrar and arranged for transfer to Intensive Care. No additional interventions were implemented at this time, and it was held that the timing of transfer was appropriate. The on-call physician and registrar discussed the patient, and the physician was satisfied that she had been appropriately investigated and treated. The Commissioner held that the physician acted appropriately.