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PostPosted: 30 Aug 2016 21:16 
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Ms. A, a 40 yr old IT consultant developed severe headache, blurred vision and nausea at work. An ambulance was called as symptoms worsened. She was seen in the A&E dept of the local hospital. The doctor who examined her recorded that her head felt heavy and she was breaking out in a cold sweat with throbbing frontal headache radiating to each temple.

Her temp was 35.4 C, BP 152/96, Pulse 58/mte and she had tenderness over her temporal muscles. Neurological exam normal with negative Kernig’s sign. She had no sinus tenderness or neck stiffness. There was no family history of migraine and she had no past medical history. She was given IM Metaclopramide and Diclofenac.

The A&E doctor discussed discussed her symptoms with another doctor who suggested hrly neurological obs and analgesia. She was given intravenous fluid and analgesia. Apart from ESR being slightly raised (30mm), all other blood investigations were normal. Two hrs later although she still had some head ache she was feeling better and had no dizziness or blurred vision. Her symptoms were diagnosed as migraine headache and she was discharged with advise to return if her symptoms got worse.

She returned to work 2 days later with some persistent headache but preferred to work in a dark room. The following week she went to see her own doctor. He listened to her history and read the hospital notes. As she still had a throbbing bitemporal headache he examined her. He recorded her BP to be 130/80, there was no carotid bruit and the neurological examination was normal with no papilloedema.

He the explained to her that it might be due to stress at work. As she had had blurred vision he sought an ophthalmology opinion. He also thought an MRI scan would be useful but did not request the scan. Over the next 3 weeks Ms. A continued to have head ache with varied intensity. She did not seek further advice as she thought it is unlikely to be anything serious as she had been examined both at the hospital and later by her family doctor who had both reassured her. She thought the headache will pass in time.

One month after the initial symptom started, she left work early as she had another severe bout of head ache. While brushing her teeth in the bathroom, lost consciousness and collapsed. She vomited twice before being rushed to the hospital. On arrival at the A&E the GCS was recorded as 6/15. Resuscitation was attempted but following an urgent CT scan of her brain she died. The scan confirmed a large subarachnoid haemorrhage involving the 3rd and 4th ventricle on the left side and a frontal intracerebral haemorrhage.

The hospital and her family doctor were sued as they had not taken the sudden onset of severe headache seriously enough and did not investigate her properly. Although her family doctor thought about a scan when he was not sure enough of the diagnosis, he did not request the scan. Experts who investigated the claim came to the conclusion that persistent severe headache was suggestive of subarachnoid haemorrhage and the patient should have been properly investigated and should have had a scan.

Learning Points suggested by MPS are:
1. It is important to revisit a colleague’s diagnosis particularly if the patient’s condition changed.
2. Her family doctor was misled by the diagnosis made at the hospital where the necessary investigations had not taken place. However as her symptoms were severe and persistent he should have excluded a more serious cause before concluding that it was caused by stress and anxiety.
3. When she was seen in the hospital her BP and pulse rate were not entirely normal. This should have prompted them to order a scan.


The claim was settled against the hospital and her doctor for a moderate sum (£10000 +)

This was a case reported in the Case Book of MPS last year


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