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No fundoscopy, no defence

01 May 2014

Miss Z, a 17-year-old sixth form student, visited Dr B at the end of the summer term of school after a stressful exam period. She was feeling generally unwell with a sore throat and some vomiting. Dr B reassured her that she was probably rundown following her exams, and she was likely to have picked up a virus. She had planned to go to America with her family over the summer, so he advised her to return to the surgery if her symptoms persisted when she came home.

A month later, Miss Z felt no better and returned to the surgery, this time seeing Dr Q. She complained of ongoing nausea, neck pain and headaches. She also noticed that her vision was ‘blanking out’ every few days. Dr Q documented a normal pulse and blood pressure and noted “normal cranials”. Miss Z did not recall an eye examination taking place; however, Dr Q maintained that fundoscopy would have been part of his cranial nerve examination. He arranged some blood tests and a review with the results.

The bloods were all normal and Miss Z was not seen again for a further two months. She again consulted Dr Q, this time complaining of weight loss along with a persistent sickly feeling. She was also experiencing visual loss on a daily basis. No record was made in the notes. Further blood tests were arranged.

Over the next month, Miss Z consulted Dr Q twice, and on both occasions the weight loss was the focus of the consultations. Dr Q attributed the symptoms to stress as deadlines for coursework were looming. On their last meeting, Miss Z complained of vacant episodes where she described a complete loss of vision. This prompted Dr Q to make an urgent referral to the local neurology service, but there was no documentation that an eye examination was performed.

After five days of waiting for the neurology appointment, Miss Z was taken to an optometrist by her mother due to ongoing visual disturbance. The optician found severe optic neuritis in both eyes, complete loss of disc margins and tortuous blood vessels with dot haemorrhages. An urgent referral was made to ophthalmology.

Dr Q received a phone call from the optician to expediate the referral during his busy on-call. He had several home visits and admissions so it was a day later when he managed to write the referral letter. He documented that Miss Z’s vision had markedly worsened over the weekend, and after a period of the symptoms all subsiding she was now waking each day with headaches and nausea.

The next day (17 weeks after first presentation) Miss Z was seen by an ophthalmologist and an immediate hospital admission was arranged. An astrocytoma of the third ventricle was diagnosed and a shunt inserted that day to relieve the pressure. The tumour was subsequently excised. However, despite resolution of the papilloedema, her vision deteriorated further. She was left with perception of light in the left eye and movement vision in the right, and registered as severely sight impaired.

Expert opinion agreed that the delayed referral led to Miss Z’s visual loss. If an appropriate referral had been initiated when the visual symptoms were first described, then it is likely that significant loss of vision would have been avoided. The case was settled for a high sum.

Learning points

  • As ever, clear documentation of a consultation is essential. Your standard of note-keeping says a lot about your practice. If you can demonstrate that your notes are generally of a high standard, it may assist you if you haven’t mentioned something in the notes.
  • If Dr Q had recorded the patient to have “no visual disturbance” and later “normal fundoscopy”, that would have been more convincing than no mention of symptoms at all, when the patient clearly recalled reporting problems.
  • Fundoscopy is an essential examination and can assist in the diagnosis of many diseases.1 In this particular case, early fundoscopy could have prevented loss of vision. Experts commented that if Dr Q had carried out fundoscopy in his initial consult (as he said he did as part of a cranial nerve exam) then he failed to identify papilloedema, as it is likely to have been present at this time.
  • If you do suggest a patient consults an optician to obtain a more thorough and immediate check-up, you should ensure that safety-netting is in place by arranging a follow-up consultation.
  • Remember red flag symptoms,2 especially in patients who may be presenting with vague non-specific symptoms. Ask the important questions, document what has been done and record any important negatives.

References

  1. Chatziralli IP, Kanonidou ED et al, The value of fundoscopy in General Practice, Open Ophthalmology Journal, 6: 4-5 (2012) www.ncbi.nlm.nih.gov/pmc/articles/PMC3308212/
  2. SIGN, Diagnosis and management of headaches in adults: Clinical Guideline 107 (2008) www.sign.ac.uk/pdf/sign107.pdf