Mrs B, a 30-year-old teacher, saw her GP, Dr J, eight times over a period of four months. She had suffered headache, low mood, vomiting, dizziness, anergy and a bad taste in her mouth. During this time, Dr J diagnosed a depressive illness and migraine.
When Mrs B next saw Dr J she told him she was feeling excessively tired and sleeping too much, had brief episodic headaches and had noticed her balance was poor. Mrs B’s husband accompanied her and told Dr J that his wife experienced episodes of confusion and disorientation.
Dr J examined the patient, finding slightly impaired co-ordination in the left leg and right arm. He noted that her knee and biceps jerks were normal and that her pupils were equally reactive to light. Dr J referred Mrs B to the community psychiatric nursing team and a consultant psychiatrist, Dr V.
The next day Mrs B came back to the practice. She saw another partner and told of her persisting headaches, blackouts and inability to function as noted by her husband. Her husband expressed his doubts that her symptoms were due to depression. Mrs B described episodes of shaking which she thought were fits. On examination it was noted that her fundi were normal. Mrs B was referred to Dr T, consultant physician.
Mrs B was seen by Dr T’s SHO, Dr L, a few days later in outpatients. Dr L noted her various symptoms, including chronic paroxysmal vomiting. Dr L documented equally reactive pupils, ‘eyes normal’ and ‘no focal neurology’. He suspected depression, early dementia or migraine and discussed the case with Dr T. Blood tests and a CT scan of head were arranged.
Mrs B saw Dr V in the psychiatry clinic. Dr V expressed an opinion that Mrs B was ‘maintaining a sick role by somatising her current problems’. Dr V arranged follow up for a month hence. Shortly after this, Mrs B was admitted as a psychiatric inpatient at her husband’s request.
On admission it was noted that she retched and vomited regularly. A neurological examination was noted as ‘CNS – intact’. Mrs B had her CT scan and a note was made in the records that its result was awaited.
Unfortunately, nine days after her admission, Mrs B was found dead in her bed. A postmortem revealed a large glioma replacing much of the right cerebral hemisphere’s white matter, with a surface nodule and evidence of recent haemorrhage. The cause of death was certified as ‘I(a) Cerebral oedema, I(b) Malignant right cerebral glioma.’
Histology revealed an anaplastic astrocytoma arising within a well-differentiated astrocytoma.
A claim against Dr J alleged an unacceptable delay in referral for expert advice.
We took advice from a psychiatric expert who was most concerned at the lack of adequately documented physical examination or assessment of cognitive function by the psychiatric team.
It was felt that Dr V’s assessment of the maintenance of a sick role by somatisation was ‘an utterly premature diagnosis, because he did not know what physical condition she might have to justify her acting like a sick person.’ The history of headaches and vomiting was felt to have pointed clearly to an organic cause of the symptoms.
The recording of physical examination with terms such as ‘CNS – intact’ was deemed substandard. The failure to document fundoscopy formally was seen as an important omission. At various points in the nursing notes there are accounts of what was thought to be ‘histrionic’ behaviour.
This interpretation was used to justify the assumption of a psychological cause for the symptoms, which the expert felt ‘beggared belief ’.He observed that ‘Psychiatrists are taught to look more intently for organic disorder when hysterical mechanisms are suspected, because various brain conditions can manifest in the release of hysterical symptoms or mechanisms.’
A physician expert found it ‘incomprehensible’ that a lady of Mrs B’s young age, presenting with her constellation of symptoms, was seen in isolation by an SHO. Although Dr L had thoroughly examined Mrs B, a more experienced practitioner might have suspected a space-occupying lesion.
It was felt that earlier, more urgent, attempts at formal diagnosis may have ameliorated Mrs B’s terminal condition. An oncology expert felt that earlier diagnosis and appropriate treatment could have significantly lengthened Mrs B’s lifespan, although curative therapy was unlikely.
The claim was settled, with the hospital providing the medical and psychiatric services accepting 50% liability.
- Specialisation - Take care that you don’t view your patients purely through the narrow lens of your specialty. It’s important to fully appreciate symptoms and signs that could suggest a diagnosis other than those with which you normally deal.
- Reviewing diagnoses - A willingness to change or question an established diagnosis, made by yourself or others, is an invaluable attitude for a doctor to possess. Many cases we see illustrate that a failure of this process is the primary fault. Nobody can be expected to recognise every diagnosis, every time, but it’s vital to be able to recognise when you might be mistaken or in doubt.
- Supervising junior colleagues - If doctors-in-training see patients on your behalf, ensure that they are properly supervised and see cases that are appropriate for their level of experience. It’s a good idea to ensure that new outpatients are seen by a relatively senior member of the clinical team. If a junior colleague makes an assessment, it’s still wise to see the patient, even briefly, to satisfy yourself that the major features of the case are correct. This also provides a good teaching opportunity.
- Stigmatising mental illness - Be careful not to stigmatise patients because of psychiatric aspects of their illness. A report by a working group of the Royal College of Psychiatrists discusses these issues and can be viewed at the RCPSYCH website. Their ‘Changing Minds’ campaign explores these issues. See also, Crisp AH et al, ‘Stigmatisation of people with mental illness’, Br J Psychiatry, 177:4-7 (2000).
- Physical assessment of psychiatric patients - An illuminating tutorial based on a case report outlines common pitfalls encountered in this process, and has useful references, available at www.webmm.ahrq.gov/cases.aspx?ic=5.