Fifty-five-year old Mr P emigrated from his home country ten years ago from overseas and secured a job as an administrator in a factory. He registered with GP Dr W soon after arriving in the country and mentioned during his first appointment that he had suffered with long-standing back pain for over a decade.
Mr P became well-known at the surgery, as he was often argumentative and confrontational towards staff. Over a period of three months, Mr P attended his GP several times complaining of neck pain, stiffness and loss of strength in both arms. It was documented that he would routinely demand sick notes from Dr W in an aggressive manner and was adamant that the doctor didn’t like him. He repeatedly insisted that he should be provided with an orthopaedic chair for work, to ease his neck.
The hostile behaviour of the patient meant that clinical examination was usually difficult and Dr W would try to keep the consultations as short as possible. Full neurological examination was only performed once when Mr P first presented and it appeared normal at this time. Despite reported progression of his neurological symptoms, examination was never repeated in subsequent consultations. Mr P began to complain of increased heaviness in his arm, which prompted Dr W to request a cervical x-ray, which showed some age-related degenerative changes. A routine referral was then made to rheumatology. Once again, no neurological examination was conducted.
While awaiting his appointment with the rheumatologists, Mr P was admitted to hospital after a fall; he was found to be tetraplegic. Further investigations confirmed his symptoms were due to a large tubercular abscess in the neck with destruction of the C4 vertebrae and pus in the epidural space. Mr P required extensive treatment and following a long hospital stay, he remained tetraplegic on discharge and required help with all normal activities of daily living.
The case could not be defended as expert opinion found that Mr P was not examined early enough, despite repeatedly attending with his symptoms. It is likely that a full recovery would have been made if diagnosis had been made sooner.
The case was settled for a high sum.
- Lalanda M, The Challenging Patient, Casebook 17 (2) (2009)
- Williams S, Tunnel Vision, Casebook 19 (2) (2011)