35: A swollen lip in a 56-year-old man

Case 35 A swollen lip in a 56-year-old man


James was a 56-year-old man. He was hypertensive with a strong family history of coronary disease. He was taking aspirin, a statin, a beta blocker and had recently started an ACE inhibitor for blood pressure control. He consulted Dr Patten after Monday morning surgery with a history that, on the Sunday evening his lip had become very swollen when he drank coke with his children in a fast food restaurant. His lip had reverted to normal size after a few hours.


What would you do now?


Dr Patten considered that it was most likely an allergic reason to the coke and advised him to avoid the drink in future. Three weeks later James consulted a colleague with a swollen itchy scrotum. The general practitioner considered it was probably an allergic reaction to washing powder.


What would be your differential diagnosis and how would you discriminate between them?


A month later James consulted Dr Patten again. He had had a recurrence of a rather severe back pain after lifting his son’s drum set into the car. He was taking paracetamol but the pain was not controlled. Dr Patten prescribed diclofenac and co-codamol.


The next day, after taking the diclofenac, James began to experience shortness of breath and his face and tongue started to swell. His wife called an ambulance but James suffered a respiratory arrest from which he was resuscitated. In hospital he was diagnosed with anaphylaxis caused by taking diclofenac and possibly contributed to by being on an ACE inhibitor.


He brought a claim against Dr Patten and his colleague alleging that they should have recognized that the swelling of his lip and scrotum were suggestive of angio-oedema and that the ACE inhibitor should have been stopped. It was alleged that James had some degree of memory impairment from his hypoxic episode.


Do you think his claim will succeed?


Expert comment


The vast majority of claims against general practitioners are for failure to diagnose or delay in diagnosis or referral. However, a proportion are about negligent prescribing, failure to adequately monitor drug therapy (for example lithium, phenytoin, amiodarone or methotrexate) or failure to recognize significant side effects.


In this case it was not clear that Dr Patten recognized that the episode described by James was due to angio-oedema. The rapid swelling of the lip followed by relatively rapid resolution was typical of the condition. Scrotal swelling is also common.


Urticaria, angio-oedema and anaphylaxis are all related conditions. Urticaria and angio-oedema both cause swelling of tissues because the small blood vessels (capillaries) abruptly leak fluid into the tissues. With urticaria the leakage occurs into the superficial tissues of the skin. With angio-oedema the same process occurs with deeper tissues – the dermis (lying below the superficial skin) and mucosal tissues that line the mouth, tongue and airways. The main concern, of course, is the possibility of life-threatening anaphylaxis or airway obstruction. Urticaria is very common in primary care. Angio-oedema is regularly seen but is less common than urticaria. Anaphylaxis is thankfully rare and occurs approximately in 1 person in 10 000 per year and most general practitioners will only encounter it a few times in their clinical career (Ewsan, 1998).


In this case Dr Patten should really have been aware that one of the problems with ACE inhibitors is an increased risk of angio-oedema.


A reasonable general practitioner should take a very careful history with angio-oedema, because of the potential seriousness of the condition for the future (even if the patient is not currently unwell). The history should include unusual exposures to possible allergens and a drug history.


Drugs, especially penicillins and aspirin, are a common cause of urticaria, angio-oedema and anaphylaxis. In addition regular prescription medication should be checked. Angiotensin Converting Enzyme Inhibitors (ACE inhibitors) are well-recognized causes of urticaria and angio-oedema. In the British National Formulary (BNF) angio-oedema is listed prominently as one of the commoner side effects of ACE inhibitors.


It is not possible for general practitioners to have an encyclopaedic knowledge of the side effects of all drugs. However, many symptoms are caused by (and often unrecognized as) drug side effects. A general practitioner should have a very low threshold for consulting reference texts such as the BNF.


Legal comment


Starting at the question of damages, if James can prove his case, then he will be compensated for the collapse he experienced. He will also receive damages for his memory impairment, if a neurologist concludes that this was probably due to hypoxia during the episode.


The respiratory arrest was undoubtedly caused by the angio-oedema, so the question that needs to be addressed is: should the general practitioners have diagnosed the condition and stopped the prescription of the ACE inhibitor? The expert opinion above suggests that although Dr Patten and his colleague may not be criticized for failing to realize that James was suffering from angio-oedema, they should have consulted the BNF and this would have led to the diagnosis and revealed the ACE inhibitor as the cause of the condition. On this analysis, the claim will have to be settled.


The value of the claim is difficult to assess without precise information over the level of memory impairment and how it affects James’s life and in particular his employment. The claim could be worth tens of thousands or several hundred thousand pounds.





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Apr 16, 2017 | Posted by in NURSING | Comments Off on 35: A swollen lip in a 56-year-old man

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