Slow bleed - medical case study

Day 1

Dr B, a recently qualified GP, is working as a locum at a large urban practice. A request for a home visit has been made by Mrs L on behalf of her husband John. He had been mowing the lawn and felt a sudden sharp pain in the back of the head followed by a severe frontal headache and vomiting. Dr B attends the patient two hours after the call has been made and finds John sitting up in bed still suffering with headache. On examination there is no evident rash and the patient’s pulse, blood pressure and temperature are normal. Examination of the eyes discloses no aversion to bright light, no abnormality of the pupils and normal ocular fundi. John does complain of tenderness in his neck but examination reveals no obvious stiffness. The patient suggests he may have “pulled something” playing tennis the day before. A provisional diagnosis of migraine headache aggravated by muscle strain is made and Dr B prescribes Migramax sachets. He tells John and his wife to call back if there is no improvement.

Day 2

The next afternoon Dr B phones the patient for follow-up. John sounds normal and bright on the phone and says that although he did not sleep well the night before the pain has eased and he is feeling better. Dr B advises him to phone if he has any further problems.

Day 3

John has another poor night’s sleep and in the morning feels extremely unwell. Mrs L takes him to Accident and Emergency. On arrival his Glasgow Coma Score is recorded as 13, indicating some mild neurological impairment. A CT scan is organised and during the procedure John’s level of consciousness deteriorates rapidly and he requires artificial ventilation. The CT scan shows a haemorrhage in the fourth ventricle and hydrocephalus. A ventriculo-peritoneal shunt is performed to reduce pressure on the brain and John undergoes a tracheotomy to help his breathing. He is then transferred to intensive care where his condition gradually stabilises but he is left with significant neurological impairment.

Six months later

A letter is received by the practice from solicitors acting on behalf of John requesting copies of his medical records with a view to pursuing a medical negligence claim against Dr B. The request is forwarded to an MDDUS adviser along with the patient’s records. Prior to his intracranial haemorrhage John ran his own travel business. The condition has left him physically disabled with speech and language difficulties. It is uncertain if he will ever work again which makes it potentially a high-value case for MDDUS.

AN MDDUS adviser contacts Dr B and asks for his account of the case and this is sent along with the patient records to an expert in primary care medicine. In his report the expert finds nothing to indicate that Dr B departed from what would be expected of a “competent general practitioner acting with ordinary care and skill.” The patient records indicate that Dr B performed a comprehensive physical examination and that he had considered possible serious diagnoses such as meningitis (checking for fever, rash and neck stiffness) and raised intracranial pressure (examining the pupils and ocular fundi). Migraine was a reasonable diagnosis given the symptoms but Dr B also instructed the patient or his wife to call back if symptoms did not improve or grew worse. In the patient’s notes Dr B had also written “??admit” indicating preparedness to seek specialist assessment if the situation changed. Intracranial haemorrhage can be difficult to diagnose. Patients experiencing major haemorrhage will report “explosive” headache followed by dramatic collapse but small bleeds can cause premonitory headaches of lesser intensity and the diagnosis may be recognised only in retrospect. The MDDUS adviser forwards a copy of the expert report to the patient’s solicitors. Two months later another letter is received by the patient’s solicitors indicating that the case will not be pursued further.

Key points

• Have a high index of suspicion in unremitting severe headaches with nausea and vomiting – although intracranial bleeding rarely presents in general practice.

• Ensure that the patient and/or family are clear about when to get back in contact should the condition fail to improve or worsen.

• Keep accurate notes of all clinical findings (positive and negative) and advice to patients in order to clearly justify clinical decisionmaking.