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A presumptive diagnosis



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I had only been in practice a few months when Claire walked into my surgery. She was a sensible lady who was complaining of recent amenorrhoea, abdominal distension and nausea, especially early in the day. There was slight weight gain and she was feeling tired all the time and looked washed out. She denied being pregnant, but was vague about her sexual history and when I found she had a uterus consistent with a 12-week pregnancy I had no doubt, and told her as gently as I could. This was a shock to her, but I arranged for her to have a scan and come back for the result.

Halfway through a busy surgery the following morning, I took a call from my radiologist. As I picked up the phone I thought it strange that they would ring me about a simple dating scan. The report hit me like a brick between the eyes – a large, rare form of uterine tumour, almost certainly metastatic and highly aggressive. I sat in silence for a long time letting this sink in, realising that another brick in the wall of my youthful medical certainty had just crumbled.

Somewhat to my surprise (and relief), Claire came back to me for her follow-up care after surgery and bore me no ill will for my presumptive diagnosis. In fact, she was grateful for a relatively early diagnosis, but this did not in truth make me feel any better at all.

There followed long rounds of chemotherapy and radiotherapy, all borne with a magnificent fortitude that I found genuinely humbling – before the initial assessment proved tragically correct. Claire died peacefully just over a year after she first walked through my door. What I learned from Claire was simplicity itself: always listen to what the patient tells you, because they just might be telling the truth.

I also found out that a GP should never be too quick to come to a diagnostic conclusion, however obvious that conclusion may appear. And although common things are common, uncommon diagnoses do happen and rare ones still happen too.

I also learned another great lesson: patients will forgive you for many things if you achieve a quick diagnosis, however bad that diagnosis may be.

Although Claire had all the classical signs and symptoms of simple pregnancy, the relatively large size of the uterus, significant tiredness and the fact that her weight had only marginally increased could, in retrospect, have made me think twice about the diagnosis.

Claire changed my practice in two ways. First, she made me realise that life in GP-land is all shades of grey, not black and white, and that there’s no substitute for experience. Second, I now try to think twice about any diagnosis – to check and then check again. These days I’m so busy I can’t remember the patients I saw this morning, but 25 years later I still remember Claire.

Oh – and one more thing. She was 17 years old.

Dr Roger Henderson is a GP in London and a columnist for The Sunday Times.

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