Mr T, an 85-year-old retired accountant, went to see his GP, Dr L, because he had felt unwell for a couple of days with a severe left-sided headache. The pain was worse on eating and Mr T had noticed transient loss of vision and flashing lights. Mr T had also lost some weight. Dr L prescribed co-dydramol.
Dr L reviewed Mr T a week later. Mr T was no better and reported being unable to eat due to headache and jaw pain. Dr L continued the same treatment. Shortly after this Mr T contacted NHS Direct for advice about his symptoms. He was advised to seek a medical opinion that day and Dr L visited Mr T at home. Dr L diagnosed arthritis of the jaw and prescribed diclofenac.
A few days later Mr T saw an optician who noted a history of ‘jaw arthritis’ along with headache and blurred vision in the left eye. Left-sided visual acuity was recorded as 6/20. The optician made no diagnosis, advising Mr T to return to his GP.
Dr L saw Mr T again two days later and treated him with chloramphenicol eye drops, diagnosing blepharitis of the left eye. The next day Mr T became blind in his left eye and was referred urgently to hospital. He was treated with highdose steroids for temporal (giant cell) arteritis. He did not recover his eyesight.
Mr T started a legal claim against Dr L.
A general practice expert witness noticed that the patient’s version of events differed significantly from Dr L’s, whose notes had not recorded the visual symptoms or pain on eating. Records showed that Mr T had reported these symptoms to NHS Direct and the optician.
The expert was critical of Dr L’s handling of the case particularly, ‘the brevity of the notes, which specifically fail to record any of the significant negative findings that should have been sought on history and examination’. An ophthalmology expert agreed that Dr L’s assessment and treatment of Mr T was below an acceptable standard because he had failed to consider a systemic cause for the symptoms.
We explored whether or not any liability was due to NHS Direct or the optician but were advised that there was no evidence of a breach of duty on their part, as both had advised urgent medical attention. We settled the case for a sum equivalent to £25,000 (US$44,000) plus costs.
Giant cell arteritis – Failure to consider giant cell arteritis as a diagnosis is a regular cause of claims. In this case the fault seems to have come from not recognising the symptom of jaw claudication, which is virtually pathognomonic for the condition. Because of the time-sensitive nature of the diagnosis and its damaging consequences, it should be borne in mind whenever an older patient complains of a new headache.
Useful screening questions include asking about:
- weight loss;
- jaw claudication;
- scalp tenderness;
- visual disturbance; and
- proximal myalgia (there is a frequent association with polymyalgia rheumatica).
Look for temporal artery tenderness and pulsatility and assess visual acuity and fields. It is important to document that these factors were assessed. For an overview of a safe approach to acute headache see our previous article in Casebook.1
An excellent tutorial on the condition is available at emedicine
- Kavanagh S, Diagnosing acute headache. Casebook 2003 3 (August 2003)