This month’s case examines the failure of a clinician to refer a patient to a specialist. The clinician, Dr. M, was a 49-year old family practice physician who had been running his own practice for the past 7 years. He employed a nurse practitioner and several office staff. One of his patients was 19-year old Miss G. The teenager showed up in his office in February complaining of sinus and nasal issues. Dr. M had been seeing the patient for the past 3 years. She would often come in with generalized complaints, difficult to diagnose, which would then clear up on their own over a month or two.
After hearing Miss G’s complaints about her sinuses and stuffy nose, the physician diagnosed her with a sinus infection and prescribed a course of antibiotics. Ten days later, after the patient complained that the antibiotics didn’t help, Dr. M prescribed a second course of antibiotics.
The following August, Miss G returned with complaints of nosebleeds, and was diagnosed by Dr. M as having sinusitis with nosebleeds. As usual, the patient complained of a whole litany of issues.
“I get nosebleeds. I have headaches every day – like in the middle of my forehead. Sometimes it’s hard to breathe because my nose is stuffed. I can’t smell things well anymore – even really bad smelling things,” complained Miss G.
The doctor reassured Miss G, but neglected to note the complaints of headache and loss of smell in the patient’s record.
In September Miss G returned with sinus and nasal complaints again and saw Dr. M’s nurse practitioner. The nurse practitioner diagnosed the patient with allergic rhinitis and prescribed fexofenadine and saline nasal spray. The patient returned in October and November at which point she was noted to have an enlarged lymph node, but no different action was taken, and no referral to a specialist was considered.