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A zebra amongst the horses

01 September 2008

Mr A, an office administrator in his 40s, was referred by an out-of-hours GP to the orthopaedic on-call team at the local district general hospital (DGH). Mr A had previously worked as a mechanic, but had been forced to change career because of a long-standing back problem, for which he had an L4/L5 microdiscectomy performed five years earlier.

He now presented with a two-day history of severe back pain radiating to his buttocks and upper thighs, and weakness in the upper and lower limbs. Mr A arrived on the ward at 9pm, where he was assessed by Dr S, the surgical junior doctor on the night shift. Dr S elicited a past medical history of spinal surgery, but noted that Mr A was otherwise well. Having completed a five-day course of amoxicillin a week previously, he was now taking only simple analgesia for back pain. The patient had fallen whilst walking to the bathroom, and had struggled to mobilise subsequently. He believed that his back pain had worsened after this. Bowel and bladder function remained normal.

Dr S examined Mr A, and recorded her findings in the notes. Mr A was apyrexial, with normal observations; examination of the respiratory, cardiovascular and gastrointestinal system yielded no significant findings. Neurological examination was noted to show symmetrically reduced power in the lower limbs; palpation of the lumbar spine revealed tenderness over the lower lumbar vertebrae. Dr S therefore called the on-call registrar, Mr W, who suggested lumbosacral x-rays and routine bloods, including ESR and CRP, prior to review. Mr W, a second year registrar, arrived on the ward at 11:30pm. He took a brief history and repeated the lower limb examination. He elicited normal anal tone, and essentially normal sensation in the lower limbs. Power of 3/5 bilaterally and inability to straight-leg-raise was attributed to pain. Radiographs showed no significant loss of disc space or fractures; blood tests were normal save a CRP of 18. Satisfied that this did not represent anything sinister, Mr W prescribed stronger analgesia and suggested review the following morning.

Mr A was reviewed by the on-call consultant, Miss E on a quick post-take ward round. Miss E noted the x-ray and inflammatory markers, and advised continued analgesia, with referral back to the spinal team. Dr P, a junior doctor, made the referral on behalf of Miss E, stating the diagnosis to be “sciatica? related to previous surgery”. Mr A was reviewed by the spinal specialty registrar, Mr D, at around 4pm on Friday afternoon. A brief note was recorded, detailing power of 3/5 in the lower limbs, with decreased sensation in both feet. PR examination was normal, and reflexes were recorded as “+” throughout the lower limbs. He also noted weakness of power grip in the upper limbs. Mr D requested a CT of the lumbar spine, in light of the history of minor trauma.

Over the weekend, Mr A continued to complain of weakness, and increasingly struggled to feed or dress himself. His family complained repeatedly to the nursing staff, and were seen by the on-call SHO. During this period there was no further review by senior team members. CT was performed on Monday morning, and showed no significant loss of intervertebral space, with no fractures or other features to explain the patient’s symptoms. Mr A was reviewed by the spinal consultant, Mr P, on his Tuesday morning ward round. Mr P noted reduced power and depressed reflexes in upper and lower limbs, and referred Mr A promptly to the physicians, with a probable diagnosis of Guillain-Barré syndrome.

After a lengthy inpatient stay, Mr A made a full recovery. The patient later lodged a formal complaint about the delay in reaching a diagnosis. MPS advised Miss E and Dr P on how to respond. Their comments were incorporated into the response sent from the hospital and there were no further developments.

Learning points

  • Keep an open mind on unusual diagnoses. Patients may have more than one serious pathology; this should be considered wherever the clinical presentation does not fit entirely with your diagnosis.
  • When taking over the care of a patient, it is important not to be overly reassured by another doctor’s diagnosis. You should check the history, and examine patients yourself, to make your own assessment afresh.
  • It is important not to focus on a diagnosis without considering the differential. A provisional diagnosis should be revisited early and often, particularly where the clinical features continue to develop.
  • Patients who have no definite diagnosis should be reviewed regularly by senior members of the team. It is important that adequate handover procedures are in place, to ensure that patients are reviewed over weekend or holiday periods.
  • When a problem occurs, you should be, open and honest with the patient. Once you have established the facts, an explanation may be all that is needed to reassure a patient and avoid any escalation of the situation. If it is clear that something has gone wrong and an apology is called for, it should be forthcoming, together with a full explanation.
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