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GP's referral quandary over unexplained tiredness and abdomen pain

Three GPs share their approach to a clinical conundrum

There is something the matter with Mr Smith and you can't find out what it is. He presented two months ago with vague abdominal pains and tiredness, joking that he was falling apart at the age of 45.

Routine bloods, including glucose and TFTs, were normal and his bowels are unchanged, but you referred him anyway under the two-week rule to the local cancer unit. He has had a negative sigmoidoscopy, and waited six weeks for a barium enema (plus another for the report) before being discharged 'back to your care'.

His symptoms are no better and you are wondering whether stress at work is to blame. He doesn't fit the criteria for a two-week dyspepsia referral, direct-access ultrasound scans take weeks to arrange, and you cannot get an urgent appointment with any consultant for at least six weeks. He cannot afford to go privately, but your sixth sense isn't happy.

Dr Rachel McKenzie

'It would be unethical to buck the system and lie to have him seen'

This is a difficult situation. I always employ the rule that if a patient presents with the same story on more than three occasions, despite my best efforts to determine the cause and manage the symptoms, then they need to be seen by a specialist.

My sixth sense is telling me Mr Smith needs further assessment but this can't be arranged as quickly as I would like.

I have a few options. I could get him seen at the direct access dyspepsia clinic by lying about his symptoms, which is tempting.

I could also send him into hospital as an emergency admission, again by fabricating a story, and during an admission he would be able to have an ultrasound, other relevant investigations and get to see a consultant.

But, however tempting, this is not what I will do. It would be unethical to buck the system and lead to other patients having their assessment delayed.

There are a few other basic investigations I could do ­ other bloods, ESR, CRP, LFTs. I could also get on the phone to a consultant I have a good rapport with and explain my concerns.

They may well be able to arrange an ultrasound more quickly or even arrange to fit the patient into one of their overbooked clinics. I could also try to refer him outwith my immediate health board area as this can also sometimes lead to a patient being seen earlier.

But perhaps the answer is to look again at other factors. He mentioned work stress ­ is he depressed and are his abdominal symptoms a manifestation of this?

What about any medication he is taking, prescribed or over the counter. I once investigated and referred a patient because of diarrhoea that settled as soon as

he stopped taking an ACE inhibitor.

What about other lifestyle factors? Dietary factors, alcohol and illicit drug use can all lead to abdominal symptoms.

I could also look again at my 'sixth sense'. This might just be transference within the consultation and I'm actually picking up on his fears that there is something seriously wrong. Perhaps spending some time talking to him about his worries and offering a listening ear will lead to his symptoms resolving all by themselves.

Dr Prashini Naidoo

'What am I treating? ­ The patient's anxiety or my anxiety?'

What am I worried about? I suppose I am most worried about missing cancer. How realistic is this?

I seem to be requesting all sorts of tests on the basis of this unquantified worry. I need to take a step back and reassess. If my practice and future investigation is to be rational I need to know what the likelihood is of the above symptoms being the presentation of large bowel cancer, gastric cancer or small bowel cancer.

I also need to find out the false negative rate of sigmoidoscopy and barium enemas, and if there is a significant false negative rate, what would be the next, more useful test to request. Once I acquire this information ­ from looking up internet sources on evidence-based medicine ­ I could then talk to a radiologist and a surgeon from a position of knowledge. Sometimes, simply being in possession of the facts alleviates both the patient's and my anxiety.

What am I treating: Mr Smith's physical symptoms, his anxiety or my anxiety? At the moment I don't have a clear and focused idea of what I am treating. My plan should be dictated by the information I gather and from a frank and sensitive discussion of these facts with Mr Smith.

Mr Smith is a competent adult and as such I should be guided in my future management by his wishes and his informed consent.

But the emphasis here is on informed consent, and the expression of patient autonomy. I am failing my patient if I continue to act solely on feelings of vague unease instead of fact, even if those facts show up the limitations of modern medicine.

Dr Alex Williams

'Something's different ­ ignore your sixth sense at your peril!'

We see patients and families and build a close bond with them in both sickness and health. It then becomes obvious to us when something is different ­ ignore these senses at your peril!

First, I would arrange another (double) appointment with Mr Smith and take a more thorough history and examination. I would ask about thirst with polyuria, night sweats, weight loss or pain when drinking alcohol ­ suggesting possible lymphoma. I would also ask about foreign travel and try to establish his sexuality.

I would like to know if he has had any transient or new rashes. If he is a smoker, does he have any bone pains or episodes of haemoptysis? A thorough examination would look for clubbing, liver palms/Dupuytren's as well as skin signs of internal malignancy, including the dark discoloration in the skin creases of acanthosis nigricans, the violaceous discoloration of the eyelids of dermatomyositis or epidermoid cysts on the face or scalp suggesting familial polyposis coli.

Further investigations may include serum calcium, CRP, CPK, PSA, autoimmune profile and a feto protein. If there was an indication and with appropriate counselling, I would consider an HIV test. A chest X-ray may give valuable information.

Hopefully the examination or blood tests should give some further clues, but it sounds like time to call in a favour. I would probably get on the phone to a local general physician.

With luck, a conversation to relay all the appropriate information would lead to an 'extra' urgent appointment or a planned admission. If all else fails we could admit him as an emergency, especially if he was losing weight or developing new symptoms.

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