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Sudden, first and worst

21 August 2014

Mrs B, a 58-year-old hotel receptionist, awoke suddenly in the early hours of Tuesday evening with an excruciating headache. Within an hour she had vomited and started to have diarrhoea. She made an urgent appointment at her GP surgery the following morning and saw Dr C. Dr C made a diagnosis of food poisoning but recorded little clinical detail about the nature of the headache and its onset, focusing on the gastrointestinal symptoms. He advised bed rest and oral fluids and gave Mrs B a prescription for prochlorperazine tablets.

Mrs B remained ill throughout the next day and her headache did not abate. She continued to vomit. By 7pm her husband was sufficiently concerned to call the out-of-hours deputising service. Mr B told Dr T that his wife had a dreadful headache and was still vomiting. Dr T did not take any further history and advised continuing oral fluids.

On Thursday, Mr B phoned again and asked for a home visit. Dr K came but kept scant details of Mrs B’s symptoms, recorded her blood pressure and the details of an abdominal examination. He administered an intramuscular injection of prochlorperazine and advised calling for an emergency ambulance if things had not improved within an hour or so. This proved to be the case and Mr B dialled 999 an hour later. Mrs B had suffered a subarachnoid haemorrhage (SAH), confirmed on CT scan. As her condition was stable and she had no neurological signs on admission, she was observed and given standard conservative therapy on the neurosurgical unit.

Unfortunately, she developed a right hemiplegia soon after admission. She was left with severe weakness mainly affecting the arm, but also her leg to a lesser degree. She was able to walk with a stick but no longer able to manage behind the busy hotel reception desk, despite her best efforts. Mrs B sued all the GPs involved in her care, alleging negligence in failing to properly assess her and consider the diagnosis of subarachnoid haemorrhage.

Expert opinion

A GP expert felt that, although diarrhoea was an unusual presenting complaint, the nature of the onset of the headache, closely associated with vomiting, should have raised the possibility of SAH as a diagnosis from the first consultation. Failing that, it should have occurred to each doctor who saw Mrs B subsequently, given that severe headache and vomiting were the persisting features. Dr T made a decision based on no further useful clinical information and Dr K should have asked more about the headache. All three doctors kept scant notes, which left them little chance of defending their decisions. The claim was settled for a moderate sum.

Learning points

  • SAH is a condition that is diagnosed on the basis of a suitable history. There are rarely findings on examination, at least initially. Because of its potential seriousness it should always be considered where a sudden, violent headache comes on with vomiting, even if there are other symptoms, unless a suitable alternative acute diagnosis immediately suggests itself.
  • Diarrhoea is considered an unusual presenting complaint with SAH. However, this received wisdom seems to be misleading doctors. The UK Ombudsman in 2000 and the New Zealand Health and Disability Commissioner in 2003 report missed SAH cases where the patient presented with, among other symptoms, diarrhoea. In both cases the patients were diagnosed with gastroenteritis and sent home.
  • It is an oft-repeated but suitably true maxim that a failure to consider diagnoses other than those made by your colleagues at an earlier assessment will leave you vulnerable to poor subsequent assessment and little chance of finding out what is actually wrong.
  • A good history is the bedrock of all efficient diagnostic practice, and particularly so when working in primary care, out-of-hours, without access to previous notes. Take care to consider and exclude serious disease in this context, relying on the history to guide you.
  • The frequency of subarachnoid haemorrhage is low – 1 per 100,000 people per annum.1 This suggests that a GP might see on average two or three in their career. If you hear hoof beats, you expect horses, not zebras, but it is good practice to check.

Further reading

For a previous review of a useful approach to acute headache, considering possible medicolegal pitfalls, in primary and secondary care contexts, see: Kavanagh S,Diagnosing Acute Headache, Avoiding Pitfalls – A Guide to Practice, Casebook, 2003 (3).