Dr Tony Feltbower



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Title of action: Mrs Smith –v- Dr Brown

Court reference number: 123456

GP Expert Witness Report for Disclosure re

Mrs Smith –v- Dr Brown

dob: 16.5.54

by

Dr. A.R.Feltbower MB BChir DRCOG AFOM

General Medical Practitioner

41 Westminster Road

Coventry. CV1 3GB

Tel 024 76223565

Fax 024 76230053

Email: Tony.Feltbower@

at the request of

Brain and Brace

Solicitors

consisting of 22 pages

dated

7th March 2003

Contents

Section Page

1. Introduction – summary of my conclusions 3

2. Key Issues to be addressed and statement of instructions 5

3. Background 6

4. My opinion 7

5. Statements of compliance and truth 11

Appendices

1. My experience and qualifications 12

2. Documents I have examined in producing this report 13

3. Relevant Chronology 14

4. Glossary of technical terms 20

5. References 22

1. The writer

1. I am Dr Tony Feltbower, a full-time general medical

Practitioner. Full details of my qualifications and experience are in appendix 1. These entitle me to give an expert opinion.

Summary of the case

2. The case concerns an allegation that there was a failure to make

an earlier referral for treatment of Endometriosis[1], resulting in more extensive treatment / surgery than might otherwise have been necessary, and that inappropriate prescriptions were issued for combined preparations of Hormone Replacement Therapy (HRT) resulting in unnecessary side-effects.

1.3 There is a chronology of key consultations at Appendix 3.

1.4 I have been asked to provide an opinion regarding the standard

of care provided to Mrs Smith by Dr Brown, and whether she should have been referred any earlier for further investigation, and whether the prescriptions issued for HRT were appropriate.

Summary of my conclusions

This report will show that in my professional opinion:

5. If the Claimant’s evidence is accepted, Dr Brown has provided sub-standard care and fallen short of the standard expected of GPs in not referring for a Gynaecological opinion to confirm or exclude endometriosis.

6. If Dr Brown’s evidence is accepted, in that the only symptoms presented to him had only been present for a short time, and on detailed questioning he was not made aware of any symptoms being present for more than a few months, then although his record-keeping is sub-standard, and his examination sub-standard, his management may have been acceptable, provided he advised the Claimant to return if symptoms did not improve.

7. There was no indication for continued prescribing of a combined or cyclical preparation of HRT after January 1999. Any prescriptions that were issued for an HRT containing progestogen after this date represent sub-standard care.

The Parties involved in the case are as follows

Mrs Smith Complainant

Dr Brown Defendant

Brain and Brace Solicitors for the Complainant

Dr A R Feltbower GP Expert Witness at the request of the

Complainant

Technical Terms

I have indicated any technical terms initially in bold type. I have defined these terms when first used and included them in a glossary at Appendix 4. I have also included at Appendix 5 extracts of published works I refer to in my report.

1. Key issues to be addressed and Statement of Instructions

1. Mrs Smith presented to Dr Brown with abdominal pain that

turned out to be due to Endometriosis.

2. She was not referred until 3 years later, and eventually had a hysterectomy[2] because of the severity of her condition.

3. The allegation is that Dr Brown should have referred 3 years earlier, which may have resulted in a more conservative form of treatment.

4. Following the operation, a combined form of HRT was prescribed by Dr Brown for more than 6 months (as advised by the hospital specialist) instead of switching to an oestrogen -only preparation.

5. As a result of this, she suffered unnecessary side-effects.

6. I have been asked to provide a GP Expert Witness opinion regarding the standard of care provided by Dr Brown on 13.3.95, particularly whether he should have referred at that time to a Gynaecologist for a second opinion.

7. I have also been asked to comment on the standard of care provided by Dr Brown regarding the continuing prescriptions for the combined HRT.

8. As a GP and not a Gynaecologist, I will not provide any opinion as to any differences in outcome or prognosis if a different course of action had been taken by Dr Brown.

Background

1. This lady was found to be suffering from severe endometriosis.

2. This is a condition, where cells that normally line the inside of the womb, are situated outside the womb, usually around the pelvic organs.

3. With each period, these cells bleed a little bit.

4. This can cause pain, often severe, although the condition can also be present without any significant symptoms; the degree of endometriosis does not correlate well with the severity of symptoms.

5. These areas can then cause scarring, resulting in adhesions.

6. Cysts can form, which gradually increase in size with the bleeding from each period.

7. This condition is usually found in women of childbearing age between the ages of 25 - 40.

8. It typically presents with (often increasingly) very painful periods, and is sometimes associated with sub-fertility.

9. There are many varied symptoms associated with endometriosis.

10. Dyspareunia[3] is one.

11. Taking an oral contraceptive pill can often help relieve the symptoms of endometriosis.

12. The diagnosis can only be properly made by laparoscopy[4], although an ultrasound may suggest the diagnosis.

13. When the condition is suspected, referral to a Gynaecologist should be made so that the condition can be diagnosed and treated.

My opinion

1. I note that Gynaecological symptoms were presented to the GPs in 1979, resulting in a Gynaecological referral.

2. However, subsequent assessment by the Hospital revealed no detectable Gynaecological abnormality, and the symptoms were diagnosed as being related to her bowels, in particular, a diet deficient in fibre.

3. Although not detailed in the chronology, there were many consultations with GPs (averaging 2-4 per year) from 1981 through to 1992.

4. Only the ones I have detailed at Appendix 3 have any relation to possible Gynaecological symptoms.

5. The total number of consultations during this period represents about the average for the general population.

6. There was only 1 consultation in 1993/94.

7. The first clear reference to a Gynaecological condition is on 13.3.95, where the GP has recorded pain in the right groin before periods.

8. He has recorded a diagnosis of ‘Endometriosis?’.

9. I would expect the GP to enquire about periods, length of time the problem had been present, any other Gynaecological symptoms (eg abnormal bleeding, vaginal discharge, pain on intercourse, urinary/bowel function, contraception) and then to record relevant facts.

10. There is no record of length of history, any examination or investigations nor as to what, if any, action was taken or advice given.

11. An examination would be appropriate to at least include palpating the abdomen and performing an internal vaginal examination.

12. The internal vaginal examination would be able to assess the pelvis for other signs of endometriosis (eg pelvic organs being tender, fixed in position by adhesions, cysts, pain), as well as checking for any other pelvic pathology.

13. This should be recorded in the notes.

14. The standard of record keeping at the consultation is poor and below that expected of GPs because there is no detail of relevant questions nor examination.

15. Mrs Smith states that her symptoms had been present for 12-18 months and that they were getting worse.

16. She experienced pain with intercourse.

17. She continues that no detailed history was taken, no abdominal examination was carried, nor an internal vaginal examination.

18. If this is correct, this represents sub-standard care.

19. Dr Brown states that, as he cannot recall the consultation, his normal practice would have been to have asked appropriate questions and to have recorded any answers that caused him concern.

20. He does not state that he would have asked about dyspareunia.

21. He states that he examined thoroughly but did not undertake a vaginal examination as he did not believe it was clinically indicated.

22. I disagree: presentation of cyclical pain for even a few months, especially where there has been a previous history of an ovarian cyst, requires a vaginal examination.

23. Dr Brown continues to state that he wished to initially adopt a conservative approach to see if symptoms settled.

24. However, if symptoms had been present for 12-18 months, I do not believe this was reasonable – a referral should have been made (see para 3.13 above) which is likely to have resulted in earlier investigation, diagnosis and treatment.

25. If symptoms had only just presented over 1-2 months, then it would have been reasonable to adopt a ‘wait and see’ policy, with specific advice to return if symptoms did not settle, of if they became worse.

26. If only mild, and present for a few months only, then this could be acceptable, provided a vaginal examination had been carried out to detect any pelvic pathology.

27. I am unclear as to what diagnosis Dr Brown refers to in para 15 of his statement.

28. If he suggests that he had made a diagnosis of endometriosis, then he should have referred to a Gynaecologist anyway.

29. However, he suggests that his record of ‘endometriosis?’ was only an aide memoir.

30. If so, then I cannot find any specific diagnosis to which he can refer.

31. If Mrs Smith had returned within a few months, her symptoms not having settled, then a referral to a Gynaecologist would have been expected (see above 4.24) resulting in earlier investigation diagnosis and treatment.

32. The records are unclear as to what prescriptions were issued for HRT and when.

33. The only clear references are to Premique[5] being prescribed on 30.6.98 following her hysterectomy, and then a note on 19.1.01 that she had been changed to Premique cycle[6].

34. Following a hysterectomy, it is not normally necessary for a woman to require the progestogen content of an HRT preparation as it is only needed to control any menstrual bleeding and to reduce the risk of causing cancer of the uterus.

35. However, for Mrs Smith, it was twice advised by the Gynaecologist (in letters dated 22.6.98 and 22.9.98) to take a combined preparation after the hysterectomy to reduce the risk of a recurrence of endometriosis.

36. It was recommended that it should only be prescribed for 6 months.

37. Although there are regular consultations with the GPs following the hysterectomy, there is no indication as to when or why Premique cycle was prescribed.

38. I note that in the letter dated 22.9.98 the Gynaecologist suggests that Evorel Combi / Evorel[7] should be prescribed.

39. There is also the suggestion in the GP notes that a prescription for Evorel Combi was issued.

40. It is unclear to me any reason for the change, as it appears that she was already on Premique, having had a 3 month prescription on discharge from hospital in June.

41. The GP consultation on 18.12.98 is also confusing as a reference is made to Premique, whereas the above comments suggest that she was taking Evorel Combi.

42. However, it is at this consultation that further prescriptions for HRT should only have contained oestrogen according to the advice from the hospital.

43. In issuing further prescriptions for a combined HRT, Dr Brown has provided sub-standard care.

44. The nurse consultation on 14.5.99 for an HRT check does not state what prescription was issued – this represents sub-standard care.

45. The consultation with the GP on 18.1.00 only mentions Premique.

Statements of compliance and truth

I understand that my duty as an expert witness is to the Court.

I have complied with that duty.

This report includes all relevant matters to the issues on which my expert evidence is given.

I have given details in this report of any matters that might affect the validity of this report. I have addressed this report to the Court.

I confirm that insofar as the facts stated in my report are within my own knowledge I have made clear which they are and I believe them to be true, and that the opinions I have expresses represent my true and complete professional opinion.

Dr Tony Feltbower. date

Appendix 1

Qualifications

MB BChir LRCP MRCS 1978

Diploma of the Royal College of Obstetrics and Gynaecology 1982

Associate of the Faculty of Occupational Medicine 1991

Cardiff University Expert Witness Certificate 2003

Post-registration Experience

GP Clinical Assistant in Accident/Emergency 1984-88

GP Clinical Assistant in Rheumatology 1988-91

GP Clinical Assistant in Gynaecology 1983-96

Present Positions

Full-time GP Principle since 1982

Member Coventry Local Medical Committee

Member of Professional Executive Committee of Coventry Primary Care Trust

Employment Medical Advisory Service Appointed Doctor under 'Asbestos', 'Lead at Work' and 'Ionising Radiation Regulations' for a number of local companies.

Occupational Health Medical Officer for Coventry City Council since 1997 and many other local companies since 1992

Clinical Complaints AdviserClinical Complaints SAdC to the Medical Defence Union

AVMA registered

Registered with UK Register of Expert Witnesses

Recognised by the Law Society as a ‘Single Joint Expert’

I have written over 3000 personal injury reports on behalf of claimants and defendants since 1994, largely as a Single Joint Expert in recent years.

I have written over 250 medico-legal negligence reports, almost 50-50 for claimants and defendants.

Appendix 2

I confirm that I have received and read the following documents:

1. Copies GP records

2. Letter of instruction Brain and Brace, Solicitors dated 8th November

3. Witness statement Elizabeth Smith, dated 19.10.02

4. Witness statement Dr Brown, dated 17.10.02

Appendix 3

Relevant Chronology

7 2 78 - new patient.

Age 23.

Reference to Tonsillectomy - 1973.

Cyst on right ovary - 1977.

Caesarean section - 1977.

No serious illnesses reported.

No drugs: On Minilyn[8]

22 2 78 - problems with menstrual cycle reported.

No period for eight weeks then very heavy periods.

23 10 78 - abdo pain/feeling sick.

No diarrhoea Rx Minilyn

10 7 79 - Eugynon 30[9] 6/12

5 10 79 - only had two periods since coming off the pill.

Painful intercourse

10 10 79 - 2½/12 pain last ?????

All the time. No vomiting

Ache all the time. Painful having intercourse.

Tender hypochondrium[10] and R iliac fossa[11]. No urinary symptoms

1977 R ovarian cystectomy when 18/52 pregnant

( refer

25 October 1979 - letter to Claimant's GP (Dr Brown) from Mr Gray,

Consultant Gynaecologist who states:

"Thank you for your letter about this patient and her abdominal pain. On

examination I could detect no gynaecological abnormality to account for

this. I have initially arranged for a full blood count to be performed

together with an MSU[12] to be cultured. I have also arranged for a bran diet

as she has a rather infrequent bowel action. She will be reviewed in one

month."

3 8 84 - symptoms of stomach ache/backache/vomiting etc

Solpadeine[13] x40. Metoclopramide[14] 10mg x21

11 10 87 - symptoms of back/neck/leg ache/dizziness.

Rx Co-Codamol[15]

5 1 89 Cx[16] smear performed. Urine - NAD[17]

2 5 89 - pain reported in knee and groin with some swelling and

crepitation

Rx Naproxen[18]

18 5 89 Repeat script for Naproxen

13 3 95 - painful right groin before period. Endometriosis?.

18 1 98 - painful periods along with clots + day 1

Aged 43 . regular 5/7

Ponstan forte[19] x100 ( Smear + PV[20]

??? 98 Routine smear taken

Referred Harris ( BGH

21 April 1998 - letter to Dr Brown (GP) from Mr R E Harris, Consultant

Gynaecologist which states:

"Thank you for referring your patient, who tends to get severe pain across

her back and lower abdomen and right iliac fossa, radiating to the right

leg. It is present about three months out of every four and her periods

although she said they weren't heavy, she then said they had quite a lot of

clots. Her cycle length is fairly regular, every 28 to 34 days and she has

been admitted recently with some dyspareunia. She gets an occasional

inter-menstrual blood loss. She has had a negative smear. She had ovarian cyst previously removed during pregnancy by my colleague Fred Bassett. She smokes 20 cigarettes a day and has had three children, one by caesarean section.

On examination today, she is moderately overweight. She has a mid line

abdominal scar. The uterus is anteverted, normal size and mobile.

Straight leg raising was fairly normal. There was a bit of reduction on

the right side and hip rotation was also normal on both sides. She was,

however, markedly tender over the right sacro iliac joint and I think she

does have some possible sacro-iliac dysfunction associated with her

menorrhagia[21].

I am bringing her in to laparoscope her to make sure that she does not have anything like endometriosis and we are checking her for blood count and ESR.

28 May 1998 - letter to Dr Brown (GP) from Mr Harris (Consultant

Gynaecologist)

"Your patient attended the pre-admission clinic on 21 May 1998, for a

pre-operative assessment.

She underwent a diagnostic laparoscopy and D&C[22] today, trying to find the

cause of her low back pain and heavy periods. She had a right sided

hydrosalpinx[23] which I am not sure is the cause of her pain. Her right ovary

was slightly cystic and scarred. Her left ovary was stuck to the pelvic

side wall and the Pouch of Douglas[24] with what appeared to be endometriosis as was the left tube. There were areas of brown pigmentation within the left pelvic side wall and the left utero-sacral ligaments. The liver and gall bladder looked normal as did the caecum.

She does appear to have some endometriosis and we will consider offering either pelvic clearance or drug treatment although I am not sure that this will cure her low back problem. We live in hope."

9 6 98 - c/o RIF[25] pain worse today. Severe ( ??? down R anterior thigh. Also PV

discharge today.

Had laparoscopy + diathermy/laser to endometriosis 10/7 ago. Abdo tender

++ RIF. BS[26] normal. Also urinary symptoms - "??? ??" no dysuria

PV. V tender ++. Admit Gynae.

15 June 1998 - letter to Dr Brown (GP) from Dr N Parks - Registrar in

Gynaecology to Mr M W Gray.

"This lady was admitted on 9 June 1998 having had a laparoscopy on 28 May 1998. She had not been feeling well for two days with abdominal pain and a green discharge.

On examination she was mildly tender across the lower abdomen and she did, indeed, seem to have a yellow, thick discharge. She was started on IV

antibiotics because her temperature was 42 C. Her temperature soon settled to 36.1 C. She was changed to oral antibiotics and discharged home when the pain had settled."

20 6 98 - Med 3[27] 8/52 Abdo pains (from 9/6)

22 June 1998 - letter to Dr Brown (GP) from Dr Richards, Senior

Registrar in Gynaecology, which states:

"Elizabeth came to the pre-op clinic on 18 June 1998 and subsequent had a total abdominal hysterectomy and bilateral salpingo-oophorectomy, the

indication being severe pelvic endometriosis and right hydrosalpinx. The

finding suggested that the right tube was moderately swollen and stuck to

the Pouch of Douglas and to the uterus. The left ovary was cystic and

densely adherent to the Pouch of Douglas and back of the uterus and bowel.

The bladder was adhered to the uterus anteriorly. Fine dissections were

made to release the adhesion. Subsequently she had a routine TAH[28] and BSO.[29]

If she does well, she will be charged on the fifth post-operative day to

be seen in two months time.

We will put her on continuous combined HRT on discharge which should be changed to oestrogen only HRT after six months."

30 6 98 - TAH,BSO - on combined HRT 6/12 because of endometriosis

( Premique 3/12

20 6 98 - discharge continues - brown and smelly (

Co-amoxiclav[30] 375mg tds (21) Metronidazole[31] 400mg tds (21)

22 September 1998 - letter to Dr Brown (GP) from Dr J Bull, SHO in

Gynaecology to Mr R E Harris.

"I reviewed this lady in clinic today. As you know, she has had a

hysterectomy. She tells me that since discharge, she has had one episode

of UTI[32] which has settled with antibiotics. At the moment she is having

some dysuria[33] but only first thing in the morning.

On examination there was nothing to find that was abnormal on abdominal examination. Speculum examination showed that the vault[34] had healed well.

After discussion with the Registrar it was decided to start her on Evorel

Combi for a further three months and then to suggest that perhaps she could switch to Evorel patches. No further follow up has been arranged and we are happy to discharge her back to your care."

25 9 98 - had hysterectomy 3/12 ago. Now still complaining burning pain

both groins. S/B hospital 3/7 ago - re persisting UTI

TCI[35] for ESR/FBC[36] BP /

Thrush - Sporanox[37] 100mg od (15)

Med 3 - 8/52 - Operation/complications

20 11 98 - Med 3 6/52

Still c/o L pelvic area burning

O/e abdo tender spot L pelvis

PV - tender spot L pelvis. No deep dyspareunia

Try diclofenac retard[38] 100mg

18 12 98 - Chat re slight ?? of Premique

14 5 99 - nurse consultation - HRT check "all well".

29 7 99 - gastro-enteritis.

18.1.00 – repeat script for Premique

9 6 2000 - pain lower abdomen/hip ( knee. No dysuria

Bowels OK

Not unwell.

Groin - tender over obturator insertion

Obturator tendonitis

Discussed. Rx Try ????? 75mg I bd + Kapake[39] 4/52 - ?steroid injection

23 11 2000 - ?????? from pain

o/e back & leg movement - nil

= told abdo adhesions

painful bust - mastalgia[40]

No lump - ?reaction to Oestrogen - told to take pain killer

1 12 2000 - lower abdo pain and from loin

Pyrexia 99 - sweaty and clammy

=mane ( LHB

Cephalexin[41] 500mg 14

5 12 2000 - bellyache lower abdomen

tender lower back/hips shooting pain down leg. Bowels nad

Not eating few weeks

19.1.01 – new GP notes that following the hysterectomy, Premique was

prescribed, but then changed to Premique cycle for an unknown reason. This prompts a referral to Mr Gray, Gynaecologist.

23 May 2001 - USS[42] abdomen and pelvis.

"No pelvic masses are seen. The hysterectomy and bilateral

salpingo-oophorectomy are noted. Both kidneys are of normal size and

appearance with no hydronephrosis. The liver, gall bladder and biliary are normal. Normal spleen. Normal pancreas and abdominal aorta. Impression: No abdominal or pelvic abnormality is seen."

29 January 2001 - letter to GP (Dr Brown) from Mr Gray (Consultant

Gynaecologist) states:

"I saw this lady today. She was apparently experiencing lower abdominal

pains, breast tenderness and headaches which she has associated with the

progesterone content of her Premique. She need only have taken the combined HRT for 6 months after her TAH and BSO in 1998. I think it would be now more appropriate to prescribe an oestrogen only preparation."

Appendix 4

Glossary of medical terms

1. Endometriosis – this is a medical condition where the cells that normally line the inside of the uterus lie elsewhere inside the abdomen (usually) and with each period of a menstrual cycle, bleed a little

2. hysterectomy – operation to remove the womb

3. Dyspareunia - pain with sexual intercourse

4. laparoscopy – keyhole surgery looking inside the abdomen with a ‘telescope’ through small incisions

5. Premique - a continuous oestrogen / progestogen preparation of HRT

6. Premique Cycle – a cyclical preparation of a combined oestrogen / progestogen HRT

7. Evorel Combi / Evorel – cyclical preparation of a combined oestrogen / progestogen HRT

8. Minilyn – a contraceptive pill

9. Eugynon 30 – a contraceptive pill

10. Hypochondrium – the abdominal area just below the ribs on the right side

11. Iliac fossa – the lower corner of the abdomen

12. MSU – mid-stream urine

13. Solpadeine – a pain killer

14. Metoclopramide – an anti-nausea pill

15. Co-codamol – a pain killer

16. Cx - cervix

17. NAD – nothing abnormal detected

18. Naproxen – an anti-inflammatory pain killer

19. Ponstan forte - an anti-inflammatory pain killer

20. PV – per vagina – an internal vaginal examination

21. Menorrhagia – heavy periods

22. D&C – dilatation and curettage of the uterus

23. Hydrosalpinx – a cystic enlargement of a Fallopian tube

24. Pouch of Douglas – the name for the part of the pelvis situated behind and below the uterus

25. RIF – right iliac fossa

26. BS – bowel sounds

27. Med 3 – a sickness certificate for Social Security purposes

28. TAH – total abdominal hysterectomy

29. BSO – bilateral salpingectomy (Fallopian tube removal) and oophorectomy (ovaries)

30. Co-amoxiclav – an antibiotic

31. Metronidazole – an antibiotic

32. UTI – urinary tact infection

33. dysuria – painful urination

34. vault – the area at the top of the vagina

35. TCI – to come in

36. FBC/ESR – blood tests

37. Sporanox – an anti-fungal pill

38. Diclofenac retard – an anti-inflammatory pain killer

39. Kapake – a strong pain killer

40. Mastalgia – painful breasts

41. Cephalexin – an antibiotic

42. USS – ultrasound scan

Appendix 5

References:

1. Illustrated Book of Gynaecology 2nd edition; Mackay, Beischer, Pepperell, Wood p280-285

2. Lecture Notes on Gynaecology 5th edition; Barnes p96-98

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[1] Endometriosis – this is a medical condition where the cells that normally line the inside of the uterus lie elsewhere inside the abdomen (usually) and with each period of a menstrual cycle, bleed a little

[2] hysterectomy – operation to remove the womb

[3] Dyspareunia - pain with sexual intercourse

[4] laparoscopy – keyhole surgery looking inside the abdomen with a ‘telescope’ through small incisions

[5] Premique - a continuous oestrogen / progestogen preparation of HRT

[6] Premique Cycle – a cyclical preparation of a combined oestrogen / progestogen HRT

[7] Evorel Combi / Evorel – cyclical preparation of a combined oestrogen / progestogen HRT

[8] Minilyn – a contraceptive pill

[9] Eugynon 30 – a contraceptive pill

[10] Hypochondrium – the abdominal area just below the ribs on the right side

[11] Iliac fossa – the lower corner of the abdomen

[12] MSU – mid-stream urine

[13] Solpadeine – a pain killer

[14] Metoclopramide – an anti-nausea pill

[15] Co-codamol – a pain killer

[16] Cx - cervix

[17] NAD – nothing abnormal detected

[18] Naproxen – an anti-inflammatory pain killer

[19] Ponstan forte - an anti-inflammatory pain killer

[20] PV – per vagina – an internal vaginal examination

[21] Menorrhagia – heavy periods

[22] D&C – dilatation and curettage of the uterus

[23] Hydrosalpinx – a cystic enlargement of a Fallopian tube

[24] Pouch of Douglas – the name for the part of the pelvis situated behind and below the uterus

[25] RIF – right iliac fossa

[26] BS – bowel sounds

[27] Med 3 – a sickness certificate for Social Security purposes

[28] TAH – total abdominal hysterectomy

[29] BSO – bilateral salpingectomy (Fallopian tube removal) and oophorectomy (ovaries)

[30] Co-amoxiclav – an antibiotic

[31] Metronidazole – an antibiotic

[32] UTI – urinary tact infection

[33] dysuria – painful urination

[34] vault – the area at the top of the vagina

[35] TCI – to come in

[36] FBC/ESR – blood tests

[37] Sporanox – an anti-fungal pill

[38] Diclofenac retard – an anti-inflammatory pain killer

[39] Kapake – a strong pain killer

[40] Mastalgia – painful breasts

[41] Cephalexin – an antibiotic

[42] USS – ultrasound scan

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