Saved by the Notes

Case history

Prior to calling Mr Black into his room, Dr Young noted that Mr Black had been seen by one of the other doctors at the surgery four days prior with the problem of headaches and a provisional diagnosis of tension or migrainous headaches.

Mr Black told Dr Young that he was still suffering with headaches. Mr Black said that he was not sure about the diagnosis of tension headaches, as he felt that there was not really any tension in his life. Mr Black said that he worked as a mobile mechanic and had no stress in his  work and he was happily married with no stress at home. Dr Young then proceeded to take a history of the headaches. He established that the headaches began about a week ago. The headaches tended to come and go and were sometimes severe and sometimes mild. They did not tend to occur at any particular time of the day and there were no associated other symptoms. Mr Black said they had been quite bad for a couple of days since he saw the other doctor, but then had seemed to be a bit better over the next two days and at the time of the consult  Mr Black did not have a headache at all.

Dr Young then proceeded to examine Mr Black. He found him to be a fit looking man and he checked his blood pressure and performed a neurological examination. All was normal on examination. Dr Young felt the most likely diagnosis was tension type headaches and he spent some time discussing the diagnosis with Mr Black.  Dr Young provided Mr Black with some handouts on 
tension headaches and he also told him to seek further medical advice if his headaches were worse first thing  in the morning, or associated with nausea or vomiting, double vision or any other neurological symptom. The consultation lasted about 30 minutes.

Dr Young never saw Mr Black again, but received a discharge summary from hospital a few weeks later. Mr Black had presented to hospital three days after his consultation with Dr Young. He had experienced an increase in his headaches on that day, associated with nausea, vomiting and irritability. An urgent CT scan revealed gross hydrocephalus with cerebral oedema secondary to a colloid cyst of the third ventricle. An urgent ventricular drain was inserted, but Mr Black sustained significant brain damage and he never regained consciousness, succumbing a couple of weeks later to infection. About two years later Mr Black’s widow commenced legal proceedings against Dr Young.

Discussion

Colloid cysts are benign congenital tumors that almost always arise from the anterior third ventricle (immediately posterior to the foramen of Monro). These epitheliumlined cysts are problematic because of their location; they can cause serious
morbidity and mortality due to acute obstructive hydrocephalus, increased intracranial pressure and, rarely, intracystic hemorrhage.

Although these tumors are considered congenital, their presentation in childhood is rare. The tumors are usually symptomatic in patients aged 20–50 years. Approximately 0.5–1% of all primary brain tumors and 15–20% of all intraventricular masses (most common) are colloid cysts. 

Often, colloid cysts are found incidentally. If symptomatic, colloid cysts are associated with the classic symptoms of intermittent obstructive hydrocephalus and paroxysmal headache associated with changing head position. In reality, the presentation is typically less specific. Headache may be part of the presentation, as well as vertigo, decreased memory and behavioural changes. In addition, sudden weakness in the lower limbs associated with falls without loss of consciousness has been reported. Other symptoms are associated with signs of increased intracranial pressure (eg, papilledema, emesis). Additionally, symptoms similar to normal pressure hydrocephalus (eg, dementia, gait disturbance, urinary incontinence) have been associated with the presentation of colloid cysts.

Medico-legal aspects

A writ/statement of claim was issued by the widow  claiming damages for nervous shock and on behalf of their two children. The writ/statement of claim alleged that  Dr Young had failed to exercise care and skill, failed to take a proper history, failed to conduct a proper examination and failed to consider a more serious cause of the  headaches and failed to order a CT scan.

Expert opinion from several doctors was obtained by the defendant’s solicitors.

An expert neurologist considered the difficulties of management of headache in general practice, noting that at least 40% of the general population will have a severe episode of headache at some time in their life, necessitating time off work and presentation to a doctor. He felt that there was nothing in the history or examination that could, without knowing the subsequent history, predict the unfortunate course of events and one would have to say that there were no indications for urgent neuroimaging.

Two eminent GPs were consulted and they opined that ‘a reasonably competent and careful GP, who was given the history and obtained the results of a neurological examination which Dr Young obtained, would not have referred Mr Black for a cranial CT scan on that day’ and that ‘the diagnosis of a tension type headache in this circumstance is very reasonable’.

In view of the supportive opinions, it was felt that Dr Young had a strong case and this matter eventually went to trial.

The judge found that there was a difference in the history as obtained by the doctor and the history as outlined by the widow. However, the widow admitted that her late husband was not a particularly forthcoming man. 

The judge found that Dr Young was an impressive witness who was consistent in his recounting of what was said. He stated that if there was conflict between Dr Young’s evidence and that of the widow, then the judge preferred the doctor’s evidence. One of the GP experts had stated that the record of the examination findings was thorough and the detail in the clinical notes was to be commended.

One of the plaintiff’s GP experts was initially critical of Dr Young for not ordering a CT scan, as judged on the widow’s presentation of Mr Black’s symptoms. However, when Dr Young’s account of the patient’s history was presented to this expert, he changed his view and agreed that there was no indication for a CT scan, based on the history as obtained by Dr Young and as documented in the notes  at the time.

The question as to whether the patient should have been referred for a CT scan was then addressed. The judge found that the GP experts, as well as a neurologist and neurosurgeon felt that given the history that Dr Young obtained of headaches coming and going, but not present at the time of the consultation and responding to simple analgesia coupled with a normal neurological examination, then referral for a CT scan was not indicated. He accepted that a ‘wait and see’ approach was reasonable with advice  to the patient to take immediate steps to obtain assistance in the event that his symptoms worsened.

This case illustrates that doctors do not have to practice defensively. The court found that a thorough history and clinical examination which was well documented was what was expected of the GP and Dr Young was entitled to rely on his clinical findings. Although a CT may have revealed the diagnosis and may have changed the outcome, the court did not find that Dr Young was negligent in not ordering this test as it was not indicated on the history and examination.

The case was settled in favour of Dr Young and there were no grounds for appeal.