In response to our recent article More than just a headache: idiopathic intracranial hypertension, a GP wrote in to share his own case involving a challenging patient who has been experiencing migraines.
This is a great article and a timely warning about the potential danger of this not uncommon medico-legal issue.
The subtle presentation and commonly shared features with other more common types of migraine and its equivalents make it harder, even for an experienced clinician who has been in practice for 31 years.
I have never, (to the best of my knowledge), missed the diagnosis, yet.
However, a special thank you for this eye-opening case study as it serves as a critical warning not only for the future, but also retrospectively.
A man in his early 50s presented to my surgery asking for an "injection for migraine". After taking a detailed history and conducting an examination which was essentially normal, I requested brain imaging. The patient assured me he had already had several brain scans and seen several neurologists who diagnosed migraine headache some years ago. He declined brain imaging or even another neurological opinion.
I provided pain management (Tramal injection 100mg intramuscularly) for the acute episode of headache and after counselling and explanation of the necessity to update the brain imaging, I referred him for a brain MRI. However, he never booked to have the brain MRI, despite the fact it is covered by Medicare for unexplained headaches.
A few months later, the patient presented to my surgery requesting the Tramal injection I gave him as they were the only ones which helped his headache. I declined, indicating that to make sure we were not missing serious brain or eye diseases which could lead to blindness or even death, he must have the brain MRI done. There was no good reason why he would not have the MRI and he was not claustrophobic. I prescribed simple analgesia for the headache.
Two months later, the patient sent a family member to see me to obtain a prescription for the same injection, which I declined. I immediately rang the patient to explain that this was potentially dangerous as we might be missing serious brain or eye diseases. I learnt from the family member that he usually obtained the injections from ‘after hours’ doctors when he got a headache. I explained this was potentially harmful.
After a couple of failed attempts to obtain the injections from me, the patient finally had his brain MRI done. The MRI showed features suggestive of IIP, tortuosity of the optic nerve sheath complex, which raised the possibility of benign intracranial hypertension as a potential cause.
After explaining the meaning of these findings and the risk of losing vision/field or vision (or part of it), permanently, I immediately referred the patient to a neurologist. I have not seen him since then.
A reminder letter was sent to the patient three months from the date of the referral as I had received no letters from the neurologist to indicate they had seen him.
Six months from the date of the brain MRI and referral to a neurologist, and I still have not received any feedback from the neurologist and I have not seen the patient.
I even personally rang the neurologist's rooms and was told the patient had never made an appointment.
After reading the case study published in the Avant newsletter, I mailed the patient another reminder letter, this time via registered mail. I will be awaiting his reply.
Dr Mark Woodrow, MBBS, MBA, GDAppLaw, GCArts, GCertEM (ACEM), Claims Manager / Medical Advisor – QLD, Avant, responds:
The GP member’s history of management of this patient is excellent. It is also necessary to emphasise the importance of documenting advice regarding the potential consequences of the patient not following their advice. Accurate and contemporaneous record keeping is essential not only for good patient care but also in the event of a claim or complaint against a doctor.
Download our factsheet, Medical records – the essentials or complete our eLearning course, On the record: medical records and documentation.
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