Mr G, a 29-year-old tiler, went to see his GP, Dr K, in 1999, complaining of occasional brief spells of feeling faint when returning from work. Dr K saw Mr G again for a full examination, but found no abnormality. He did not document the specifics of his neurological or cardiovascular examination.
Mr G returned a few months later complaining of regular, short-lived frontal headaches and episodic leg weakness. Dr K conducted a full examination and found no abnormality. Again, the specific negative findings were not documented. Dr K conducted some screening blood tests.
Mr G returned the next year with the same symptoms, which seemed to be triggered by moving his neck and so a cervical spine x-ray was ordered. It was normal.
Three months later, Mr G collapsed at work and was admitted to hospital in a coma. A CT scan showed a large occipital space-occupying lesion and temporal lobe coning. Mr G did not recover and was declared brain dead. A biopsy showed the mass to be a non-malignant meningioma.
When Mr G’s family alleged negligence, we asked a GP expert to examine the case notes.
The expert found an ESR result from the screening blood tests. This was grossly elevated at 178 mm/hr. The result had been stamped by the practice and filed without any plan of action being indicated. In the light of this information, the expert felt that the management of Mr G from that point on could not be supported.
This abnormal result in a man with unusual and persistent symptoms should have prompted a referral for neurological or general medical advice.
However, the expert felt that the approach had been entirely appropriate up to this point, with frequent examination and screening bloods being done in a case that had presented quite unusually.
Unfortunately, these tests were not acted upon; this was the fundamental error which led us to settle the case for a sum equivalent to £250,000 (US$480,000), once we had expert neurosurgical opinion that earlier intervention could have saved Mr G’s life.
- A reliable system for ensuring that test results are seen and acted upon is crucial.
- Diagnosing intracranial space-occupying lesions can be difficult. The rubric below is helpful for assessing patients that could have relevant symptoms.
- Take and document a thorough history across the range of systems that might produce such symptoms.
- Perform a brief screening examination of the cranial nerves and document what was examined. Documentation of fundoscopy is particularly important.
- Check tone, power, co-ordination and reflexes in upper and lower limbs and document these findings.
- Examine any other relevant systems and document the findings.
- Consider what investigations might help and make sure the results are reviewed.
- Seek specialist advice if unsure.
- Be willing to reconsider your diagnosis in the light of evolving clinical information.
For further details on clinical features of raised intra-cranial pressure, see our previous article "Acute Headache" in Casebook 2003(3), August.