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Headaches and hypertension

01 May 2014

Mr J was 43 and unemployed. He developed headaches and complained that sunshine hurt his eyes and he was bothered by noise. He made an appointment with his GP, Dr A, explaining that he had tried over-the-counter painkillers but that they did not help when he had one of his pounding headaches. Dr A documented Mr J had presented with headaches with some features of migraine and prescribed some tramadol.

Five years later, Mr J was struggling with headaches. He wondered if he needed new glasses so he visited his optician. His optical prescription had changed and he was given some new glasses, but when his headaches persisted he decided to see his GP again.

Dr A documented that he was suffering with headaches that were present in the morning and in the evening. He checked his blood pressure, which was 110/80. Mr J was also complaining of toothache and Dr A suggested that he saw a dentist, in case the headaches were related. Dr A considered other causes of his headache and noted that Mr J had also complained of neck pain. He suggested some exercises for cervicalgia.

Mr J visited his dentist who referred him to a consultant oral maxillofacial surgeon. He thought his headaches were coming from temporo-mandibular joint dysfunction, possibly secondary to a tender wisdom tooth. He had his wisdom tooth extracted under sedation. His blood pressure was not taken at this time. At his review, it was noted that his headaches had improved and could be managed with paracetamol alone. Mr J felt better and had been able to find a job in a supermarket.

The same year Mr J became concerned because he saw blood in his urine. He made an urgent appointment with his GP. Dr A documented that he had no dysuria or suprapubic pain. He noted that Mr J was very anxious about it and referred him to urology to investigate his painless haematuria. There was no mention of headaches at this consultation and his blood pressure was not taken.

A month later, Mr J fell whilst stacking shelves at work. He couldn’t get up and noticed that his right side felt weak and his voice was slurred. An ambulance was called and took him to the Emergency Department, where a CT scan showed a large intra-parenchymal bleed with extension into the left ventricle and midline shift.

He became agitated, irritable and started vomiting. His GCS dropped to 7 and he was admitted to ITU where he was intubated and ventilated. His blood pressure was found to be 260/140. His left pupil was found to be larger than the right and was unreactive.

Mr J had a left frontal craniotomy, releasing 230ml of haematoma blood. He remained ventilated for over a week because of issues with high blood pressure. Mr J was found to have left ventricular hypertrophy on ECG and impaired renal function. His hypertension persisted after he was extubated and he was found to have grade 2 hypertensive retinopathy.

A month later, Mr J was discharged home but had developed epilepsy and significant cognitive impairment. He needed neurorehabilitation, was unable to work, and required care.

At his nephrology follow-up, his blood pressure was 150/100 despite four antihypertensive drugs, but there was no evidence of LVH on echocardiogram.

Mr J made a claim against his GP. He felt that the diagnosis of hypertension had been missed and the delay in treatment had caused his brain haemorrhage. It was alleged that Dr A had failed to take his blood pressure despite persistent headaches and haematuria. He believed that Dr A had diagnosed somatisation headache without examining him.

Expert GP opinion had only one criticism of Dr A, in that he failed to examine the optic fundi when he presented with headaches in the morning. The opinion of a professor of cardiovascular medicine was also gained. He concluded that the intracerebral bleed was likely to be due to a small vascular abnormality rather than due to malignant or accelerated hypertension.

He thought that he probably had only mild to moderate hypertension before his bleed because he had been found to have only grade 2 hypertensive retinopathy. There was no papilloedema, haemorrhages or exudates which accompany accelerated or malignant hypertension.

Expert opinion also felt that the very high blood pressure readings at the time of the stroke represented the usual physiological reaction to a cerebral bleed and did not represent the true ongoing level of hypertension. He discounted the relevance of headaches as a sign of hypertension in this case. He explained that hypertension usually only causes headache if it is malignant or accelerated, which he believed was not the case.

The case was successfully defended pre-trial and all costs were recovered.

Learning points

  • Tragic events don’t always equate to negligence.
  • MPS successfully defended the claim by gaining expert opinion from three doctors.
  • It is useful to remind ourselves of the stages of hypertensive retinopathy and remember to examine the fundi in patients with hypertension.1

References

1. www.gpnotebook.co.uk/simplepage.cfm?ID=-46858224&linkID=18777&cook=yes