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Material by Professor Omar Hasan Kasule Sr. for Year 2 Semester 1 Med PPSD session on 10th September 2008
Background
Norhayati was a 35-year old housewife with 5 living children. She was found anemic in her last pregnancy but the doctors were not worried because some degree of anemia was expected in normal pregnancy. She also gave a history of anemia in all her previous pregnancies and even in the intervals between pregnancies.
On follow-up at 3 and 6 months post delivery, Norhayati complained of fatigue all the time. She told the nurses at the postnatal clinic that her skin and palms were paler than usual. She was given iron tablets and vitamins and was told to eat a balanced diet. The fatigue and pallor persisted at follow up 12 months post-natally.
The nurses referred her to a newly-graduated doctor who took a detailed history and made a thorough clinical. He did not find any clinical cause of anemia since Norhayati was eating well, had no blood loss, and had no other correlate of anemia. He took blood to determine the level of hemoglobin which was found low but not alarming. He prescribed more iron and vitamin tablets. He informed his senior consultant about the case when they met in the cafeteria and the consultant found the management satisfactory.
A month later Norhayati visited her relatives in Temburong and on return had fever, vomiting, and leg aches. The doctors suspected malaria and ordered a blood film. The laboratory technician did not see any malarial parasites but thought that the film was abnormal. He consulted a senior hematologist who asked for new blood films to be prepared and stained in different ways. A diagnosis of neoplastic lymphoproliferative disorder was made and the patient was referred to an oncologist for treatment. The oncologist was very angry because the long delay before the diagnosis was suspected in a patient with persistent anemia.
Discussion issues
- List and discuss ethico-legal and cost considerations in the choice between symptomatic treatment and aggressive investigation of common symptoms like backache in apparently healthy individuals;
- Describe legal liability issues that arise when a serious disease presenting as an innocent common symptom like backache is misdiagnosed.