A pain in the neck

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.

Learning points

• Management of challenging patients can be very complicated and in cases like this can have devastating results. Despite the multitude of negative emotions introduced by an aggressive patient, it is important to maintain a professional approach and rule out any underlying pathology. Neglecting basics such as physical examination and reassessing for evolving signs is indefensible.
• Dr Monica Lalanda’s article on “The Challenging Patient”¹ offers advice on dealing with these difficult encounters and reflects on the elements that often contribute to a patient’s behaviour.
• An estimated one third of the world’s population is infected with latent tuberculosis, and although once uncommon in the UK, cases have increased markedly over the last 20 years, particularly among ethnic minority communities from countries where TB is widespread, and in patients with HIV. This increasing prevalence makes it a diagnosis that should be considered.
• It is important to revisit your diagnosis and examination for evolving signs. See the Casebook article “Tunnel Vision” for more information.²
• Dealing with conflict from aggressive patients can be a significant source of stress for doctors and can lead to a breakdown in the therapeutic relationship. Training in communication skills can be helpful in dealing with challenging scenarios.

  MPS runs a workshop, Mastering Difficult Interactions with Patients; visit www.medicalprotection.org and click on the Education tab.

References

1. Lalanda M, The Challenging Patient, Casebook 17 (2) (2009)
2. Williams S, Tunnel Vision, Casebook 19 (2) (2011)