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Commonly Missed Diagnoses

We all know that we make mistakes, and we learn from these mistakes. We also know that we are likely to miss certain diagnoses. The Practitioner Performance Team is, thankfully, realistic about this, and supports GPs who miss uncommon diagnoses. However, when doctors miss common diagnoses they are less supportive.

Defence organisations report that the most likely conditions for GPs to miss are, in adults; cancers, and myocardial infarction; and in children; meningitis, and new onset diabetes.

These adult conditions are relatively common, and if missed have significant consequences for the patient. Thus, most GPs are aware that these conditions should always be considered when consulting unwell patients. Despite this, these conditions are frequently missed. This raises the question "how can we change this?"

Improving cancer diagnosis

We miss cancer diagnoses when patients present with symptoms which do not fall into the commonly recognised pattern. To improve cancer diagnosis, the RCGP recommends that practices should audit regularly their cancer di-agnoses. By identifying when cancers were not identified early, we can learn what we are missing, and identify ways to prevent this in the future.

Managing new onset chest pain

Patients with chest pain generally fall into three types; those with typical cardiac chest pain, those with pain which is clearly not cardiac, and those where the diagnosis is equivocal. NICE has produced some easy to follow guide-lines for "Chest Pain of Recent Onset". This guideline has a useful tool to help identify those patients with equivocal symptoms who should be considered as having cardiac pain. We would recommend that this guidance can be used to create practice protocols, which, if followed, should help prevent missed diagnosis of MI. This guideline can be found at http://www.nice.org.uk/guidance/cg95 .

The childhood conditions, meningitis and new onset diabetes, are less common, but have similarly high impact if missed.

Meningitis

All doctors fear the day that a child presents with meningitis, though if the presentation is obvious most GPs will not miss the diagnosis. The cases of meningitis which are missed are usually in children who have a non-specific febrile illness. Meningitis Research Foundation recommends that all febrile children who do not have an obvious cause for fever should be seen and examined by a clinician, so that meningitis can be ruled out. They recommend that the minimum examination should include;

  • Presence and absence of rash
  • Temperature
  • Respiratory rate
  • Pulse
  • Capillary refill
  • Blood pressure
  • Urinalysis

If the cause for fever is not identified, the child should be referred for further investigation.

New onset diabetes

The incidence of Type 1 diabetes in children is increasing, with an estimated prevalence of 1 in 430-530. With the increasing incidence, there are an increasing number of children under the age of 4 presenting with Type 1 diabe-tes.

New onset diabetes can be easy to identify if the child presents with weight loss, thirst and polyuria. Many cases, however, do not present in this way. These children do not present with the typical symptoms. Younger children with Type 1 diabetes present with non-specific symptoms, such as lethargy and irritability. Acute illnesses, such as viral infections, can precipitate the presentation of type 1 diabetes. It is important, therefore, to exclude diabetes in children who present as more unwell than would be expected.

The Practitioner Performance Teams are clinically led, and thus when diagnoses are missed, the outcome is usually for the doctor being investigated to be encouraged to undergo further training and education. However, to avoid this occurring, we would recommend that doctors and practices regularly update themselves on these easily missed

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