Fillers A memorable patient

The importance of keeping contemporaneous records

BMJ 2001; 323 doi: (Published 15 December 2001) Cite this as: BMJ 2001;323:1423
  1. Alexander Williams, general practitioner
  1. St Thomas Medical Group Research Unit, Exeter

    Oliver was born the day after my daughter was, and I remember his mother was on the labour ward when my wife was in labour. She unfortunately had prolonged rupture of membranes that led to a stormy neonatal period with sepsis, jaundice, and feeding problems. He has had an uneventful childhood apart from an assortment of coughs and colds.

    Recently, Oliver was seen by one of our nurses with a tick on his eyelid, and this was easily removed after the application of a liberal coat of petroleum jelly overnight.

    Three weeks later he developed conjunctivitis, for which I prescribed chloramphenicol drops. He subsequently saw various doctors in the practice, the notes are well written and thorough, and in retrospect we should have made the diagnosis sooner as all the clues were there.

    Four days after the conjunctivitis, he developed a rash on his cheek, although the conjunctivitis was better. The entry reads “?erythema marginatum but heart sounds ok, no organomegally, probable viral illness.” However, there was an annotation to the entry by the nurse relating to the tick bite suggesting the tick had been present for over 24 hours.

    Several days later, he became unwell with a fever. The facial rash had resolved, but examination by another doctor showed a high temperature, enlarged tonsils, and clear urine on multistix.

    After three weeks he was still unwell, lacking energy and anorectic. He was seen by the original doctor, and the penny dropped (with a clang). The rash on Oliver's cheek was erythema chronicum migrans (ECM). This usually arises centrifugally from a tick bite, but secondary annular rashes can arise in the vicinity, as in this case. He was given high dose penicillin, and serology for Borrelia burgdorferi proved positive after a further week, confirming the diagnosis of Lyme disease.

    Fortunately Oliver developed no neurological or rheumatological sequelae and made a full and uneventful recovery, but he had given his parents considerable worry during his illness. His mother subsequently told me that she thought he had leukaemia.

    I have always been an advocate of thorough contemporaneous records, which are then a useful management tool for all members of a primary healthcare team. Increasingly, we are working as an extended team, and patients may see the nurse practitioner, health visitor, physiotherapist, or doctor. Difficulty with access may make continuity of care problematic, and it behoves all of us to read the entries of our fellow professionals as an aid to accurate diagnosis.

    I am always suspicious when a patient presents for the third time with a problem that has not resolved and am always keen to consider physical rather than psychological causes in the first instance.

    Critical event analysis assesses whether important clues have been missed in the presentation of serious or unusual diseases, and it has highlighted some shortcomings in this case from which we have all learnt a valuable lesson.

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