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A case that changed my practice – when minor becomes major

The case

‘There’s quite a few of them but they’ve all got minor stuff and I’ll help you with any treatments you need. We get through them like a hot knife through butter.’ So said the charge nurse for my shift in the GP-led walk-in centre at an A&E department.

I’d been working a lot, was tired and the substandard coffee on offer wasn’t having the desired effect. I wondered if a few ‘easy minor ones’ as the charge nurse had mentioned might be just the thing to get me going on a Saturday morning.

Two patients into this ‘see-and-treat’ session, I saw an 11-year-old boy who attended with his mother. He’d fallen off a bike the day before while getting a ‘backy’ from his friend as some other children had squirted water at them, and had hit the left side of his chest against the handlebar.

An ambulance had been called and he had been assessed by paramedic staff who felt that he had some minor injuries and bruising and gave some general advice. But his mum had brought him in as she was concerned that he was ‘not quite himself’ and ‘quieter’.

The outcome

His pulse was 110, his chest was clear and I couldn’t find anything on examination of his left shoulder. But he still looked uncomfortable and was very quiet, certainly not fitting with the somewhat adventurous personality of a boy who takes a ‘backy’ on a bike. 

As he sat there in front of me, I almost half-heartedly placed a hand on his abdomen and he immediately flinched.

With the help of the charge nurse, we moved him to a couch so that I could examine him properly lying down and it was clear that his abdomen was slightly distended and he was tender in his left upper quadrant. Given that he was haemodynamically stable, a CT scan of his abdomen was organised – which revealed a splenic laceration. He was transferred to the care of the surgical team and managed conservatively.

What I learned

My learning from this case was both general and specific. From a general point of view, I learned that not all presentations that appear minor are minor, and it is important to start from the basics – observations, history-taking and full examination. Full examination can be difficult and time-consuming, but half-hearted examination is dangerous and may result in a missed diagnosis. The value of taking the history again, and of not being influenced by the results of a prior assessment by another health professional were both emphasised to me – as was the importance of listening to parents when they feel their child is ‘just not right’, or ‘quiet’.

Specifically, I learned that blunt chest/abdominal injury always warrants exclusion of splenic injury, and that in children full examination is particularly important as they are often less able to localise pain.

On a lighter note I also learned that a ‘backy’ involves sitting on the back of a bike while another person pedals at the front.

How this changed my practice

This case modified my approach to general practice. I am now more conscious of the fact that patients who are seriously unwell might walk into the consulting room. It is nowadays no secret that doctors are under more pressure to see patients quickly. But I try to remember that the most important thing is to be safe, take the appropriate history and do the appropriate examination – irrespective of whether that falls into the allocated five- or 10-minute slot. I have also incorporated parental concern as a yellow flag in my assessment of paediatric cases.

And finally, I always carry my own jar of coffee when working in the walk-in centre.

Dr Mandeep Singh Baveja is a GP in Batley, West Yorkshire