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Take me seriously

01 January 2013

Forty-year-old hairdresser and mother-of-three Mrs T had long-term problems with neck pains and migraines. She had seen her own GP Dr W, and many of the partners in the practice, several times over the years with the same complaint.

Her symptoms had been largely attributed to muscular spasms due to her job. One day, Mrs T attended Dr W’s surgery with a headache she felt was much worse than usual. She had also experienced several episodes of vomiting that morning. Although the history of migraine was well-established, the symptoms she presented with “felt different to her usual migraine”. She described pain shooting down the back of her neck, which had never happened before. Dr W documented the consultation with one line in the notes, stating: “Migraine. Prescribed some painkillers.” There was no evidence in the records about any history taken or examination performed.

Over the next three weeks, Mrs T attended four more times with ongoing symptoms, seeing different partners each time. She asked for a private referral to a chiropractor as she thought she had “wry neck” and simple analgesia was providing no relief. Frustrated with the ongoing headache, she even attended the Emergency Department once but no investigations were carried out, based on the chronicity of her symptoms and her long history of migraines.

Four weeks from the onset of this latest, severe headache, Mrs T had a seizure followed by a fatal cardiorespiratory arrest. The postmortem showed that she had suffered a subarachnoid haemorrhage. Mrs T’s family made claims against all the doctors involved in her care, including hospital doctors, and the case was settled for a high sum.

Learning points

  • Those who reattend frequently with the same complaint might be seriously ill. A safe approach is to go back to basics, by documenting a thorough history and examination of the problem.
  • Listening to what the patients tell you remains one of the best medical tools. A patient with chronic migraine who describes her headache as different to previous ones deserves careful attention. Try not to allow a consultation to be prejudiced by what has happened before and do not let the patient’s self-diagnosis prevent you from keeping an open mind as to the cause of their symptoms.
  • SIGN have produced comprehensive guidelines: Diagnosis and Management of Headache in Adults – A National Clinical Guideline (2008)
  • NICE have similar guidance: Headaches: Diagnosis and management of headaches in young people and adults
  • Headache is a common symptom and missed SAH is a frequent source of litigation. Casebook has featured similar presentations of SAH in the past, which may be of interest:
    • MPS Casebook, Not just another headache, 17 (3) (2009)
    • MPS Casebook, Sudden first and worst, 16 (1) (2008)
    • MPS Casebook, Sudden, first and worst again, 16 (2) (2008)
  • If aneurysmal SAH is treated urgently, complications can be reduced. Kowalski et al noted that misdiagnosis of SAH in patients who initially present in good condition is associated with an increased mortality and morbidity. They suggest a low threshold for CT scanning and highlight the importance of immediate aneurysm repair – stating that rebleeding occurs in 26%-73% of patients within days or weeks if left untreated. Kowalski R et al, Initial misdiagnosis and outcome after subarachnoid haemorrhage, JAMA 291(7):866-869 (2004)
  • Remember the importance of lumbar puncture – CT scans may often come back negative.
  • Ensure that you keep accurate records, as when a claim is made, evidence is collected from a number of different sources and records may be cross-referenced. For example, hospital records on admission may contain a history that is very relevant in a claim relating to a GP’s earlier actions.