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Diverted by the diagnosis

05 May 2015

Miss A, a 40-year-old IT consultant, was talking to a colleague at work when she developed a headache, along with blurred vision and nausea. Her symptoms worsened so an ambulance was called. In the Emergency Department (ED), Miss A was triaged as moderate urgency and examined by Dr B who recorded that her head felt “heavy” at work and she’d felt herself breaking out in a cold sweat, with a throbbing frontal headache radiating to each temple. 

The notes describe Miss A lying on a trolley covering her eyes with her hands, with temperature of 35.4, blood pressure 152/96, pulse rate 58/min, and tenderness over her temporal muscles. Her neurological examination was essentially normal. Kernig’s sign was negative and she had no sinus tenderness or neck stiffness. There was no past medical history of migraine or family history of note. 

She was given IM metoclopramide and diclofenac. A record followed of a telephone discussion with another doctor, who requested that Miss A have hourly neurological observations, be given analgesia and reviewed. In the emergency observation unit, Miss A received intravenous fluid and analgesia. She had a normal full blood count, electrolytes, liver function tests, bone profile and C-reactive protein. ESR was mildly raised at 30mm/hr. 

Two hours later, Miss A was assessed and, although the headache was still present, she was feeling better and the blurred vision and dizziness had resolved. The raised ESR was noted with a comment that it was unlikely to represent giant cell arteritis. Following a diagnosis of migraine headache, she was discharged with analgesia and advised to return if the symptoms worsened.

Two days later, Miss A returned to work, though she still had the headache and preferred to be in a dark room. The next week she attended her GP, Dr X, who listened to her history and read the hospital letter, noting that she still had a throbbing bi-temporal headache worse on movement and relieved by being in a dark room. He recorded a blood pressure of 130/80, no carotid bruits on auscultation, and a normal neurological examination with normal cranial nerves and no papilloedema.

When Dr X asked about her social circumstances, Miss A became upset as she was worried she might lose her job. Dr X explained that the likely cause of her headache was an acute migraine precipitated by work stress. Due to her blurred vision, Dr X decided an ophthalmology opinion and an MRI scan might be useful to rule out a vascular abnormality and this was recorded in the notes. He prescribed Maxalt wafers and asked Miss A to call him the next day to report her progress. Later, Miss A’s partner said Dr X explained the migraine might be linked to her eyesight but did not recommend an MRI or suggest that there might be anything more serious causing it.

The following day, Miss A phoned to report that her headache was much better. Dr X recorded a discussion about a possible ophthalmology opinion and follow up.

Over the next three weeks, Miss A continued to have a headache, which varied in severity. She didn’t seek further medical advice because she expected the headache to pass, after being investigated at hospital and attending her GP. Her partner said later she had no reason to doubt the advice she had been given. 

One month after the headache started, Miss A left work early because of another severe headache. While brushing her teeth, she lost consciousness and collapsed. She vomited twice before an ambulance took her to the ED where, on arrival, her GCS was 6/15. Resuscitation was attempted but following a CT scan of her brain, she died. The scan confirmed a large subarachnoid haemorrhage involving the 3rd and 4th ventricle on the left side and a frontal intracerebral haemorrhage. 

A claim was made, alleging delay in referring Miss A, resulting in late diagnosis of subarachnoid haemorrhage from which she died. Allegedly, Dr X had failed to notice the ED records, which showed a history of sudden onset headache. He did not act cautiously and refer Miss A for investigations for suspected SAH. After considering the possibility of a vascular anomaly, he did not act and hadn’t arranged an urgent hospital admission and investigations. He’d made an unreasonable diagnosis of migraine with respect to Miss A’s age and symptoms. 

The claim also alleged that the hospital had failed to establish Miss A’s subarachnoid haemorrhage and hadn’t reviewed her appropriately in the ED.

Expert opinion

Expert opinion found that it is reasonable for GPs to rely on diagnoses made at hospital after a period of inpatient observation and investigation. In this case, however, the patient presentation to Dr X was so suggestive of a subarachnoid haemorrhage that hospital admission was essential that day to exclude a diagnosis. Dr X had reasonably considered a vascular event as a cause of the headache. However, he’d planned to wait and arrange an MRI scan if the headache did not settle with treatment. 

In this case, Dr C, an expert GP instructed by MPS, said it was not reasonable to wait before arranging referral for investigations. Dr X felt his actions were defensible. After their consultation, Miss A had his telephone number so could have phoned him at any stage. He’d instructed her to return if her condition deteriorated. He’d acted cautiously and responsibly – the patient declined medical follow-up and specialist referral the next day. She’d been investigated at ED before attending him and the diagnosis had been migraine.

Dr X had based his own diagnosis on the reported pulsating headache lasting 4-72 hours of moderate to severe intensity, aggravated by routine exertion and associated photophobia. Miss A had work stress, which may have precipitated a migraine and reinforced the diagnosis. Migraines usually present as unilateral headaches, but bilateral headaches can also occur. Miss A’s headache was frontal to begin with and then bi-temporal when she’d attended Dr X. 

Although she had no history of aura, migraines without aura are more common. In Dr X’s opinion, it did not matter that Miss A had no past history of migraine – not all patients are aware they may have experienced migraines in the past. 

The claim was settled against both Dr X and the hospital for a moderate sum.

Learning points

  • It is important to be prepared to revisit a colleague’s diagnosis, particularly if the patient’s condition ha s changed. In this case, Dr X wa s misled by the diagnosis made at the hospital, where the necessary investigations did not take place. On the day she presented to ED, Miss A’s blood pressure and pulse rate were not entirely within normal range and this should have prompted further investigation, ie, CT scan.
  • Dr X attributed Miss A’s symptoms to stress at work – although stress and anxiety can cause physical symptoms, you must ensure you have excluded any serious physical causes first. 
4 comments
  • By Harry Kelleher on 29 August 2015 05:56 An initial rise in BP on hospital attendance is surely most likely an effect of being in pain and possible white coat effect. Sudden onset of the patient's headache is a far stronger indicator of a need for urgent imaging consideration.
  • By Dr Ahmed on 05 June 2015 10:17 I think there is lot to learn from this case. In case of patients presenting with headache, one should be looking for red flag features and act promptly if there is any.

  • By BJayaratne on 05 June 2015 11:02

    It is a classic case of acute subarachnoid ha emirate, an early ct/mri at the first presentation could have saved the life.

    consultant ICU

  • By stephen wright on 04 June 2015 08:44 Weren't the raised blood pressure and slow use rate at first hospital presentation indications of raised intracranial pressure?
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