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A trip to Tobago

Some years ago a 48-year-old lady came to the surgery complaining of a rash that had been troubling her for more than four weeks.

She was a lady I knew quite well, having been a patient in the practice for many years. She had no other major health complaints and no previous history of skin conditions.

The rash itself was widespread and slightly irritable. She had tried to treat herself with moisturizing creams and antihistamines, but nothing had touched it. She told me that, since the onset of the rash, the red patches had remained in the same location, without change.

Examining the rash, I was struck by its presence on her palms, something that rang alarm bells in my dim and distant memory. The GP detective kicked in, and I noted a fading suntan on the unaffected skin. I started asking more specific questions about possible exposures, travel, and her occupation.

She explained that earlier in the year, she had taken herself on a trip to Tobago. I moved on to asking the more delicate question about sexual activity while on holiday. Indeed, she had had unprotected intercourse with a local man while in Tobago. She had subsequently suffered with vaginal discharge for several weeks, but had ignored it since it had settled down.

I tentatively suggested that the rash might be related to her intimate liaison and be that of secondary syphilis, and she agreed to have a screening blood test. We sent off TPHA and VRDL tests. A few days later I checked up on the results to find them negative. Having informed the patient, I shrugged my shoulders thinking, ‘you can’t win them all’, and went off on holiday myself.

On my return, my senior partner informed me that he had had a telephone call from the local laboratory about my patient. Intrigued by my detailed clinical information, they had sent a sample to the reference laboratory in Manchester. This had indeed proved positive for syphilis. In my absence, my patient had been whisked off to the local genitourinary medicine clinic for treatment. Not only had I saved this lady from potential dementia and death, but it was heartwarming to receive a pat on the back from my colleague. Our practice now treats positive events as learning opportunities with the same degree of significance as complaints or mishaps.

The importance of saying ‘well done’ should never be underestimated. Wouldn’t it be nice if our critics in Whitehall behaved likewise?

Dr Nadine Kale is a GP in Chesterfield.

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