Tech Talk
A GP’ s medical records are at odds with a patient’ s persistent headaches.
Smart Practice
Tech Talk
Antony Scholefield
Tension or tumour?
EXPERT OPINION
A GP’ s medical records are at odds with a patient’ s persistent headaches.
DR CRAIG LILIENTHAL
A
65-YEAR-old female presented to her GP with a three-week history of bitemporal and occipital headaches. The GP diagnosed tension headaches and referred her for an X-ray of her cervical spine, and then to a physiotherapist for treatment.
The X-ray did not reveal any abnormality other than a mild scoliosis possibly resulting from muscle spasm. Over the next four years, the patient consulted the GP on 12 occasions for a range of matters. Symptoms of headaches were recorded on only two of these occasions.
At the most recent presentation, the patient complained of tongue spasms for one month affecting her speech and eating. She also mentioned headaches involving the right side of her neck and face over the prior five years.
On examination, the GP noted atrophy and muscle fasciculation on the right side of her tongue and referred her to neurologist, who diagnosed a meningioma.
The patient was referred to a neurosurgeon who removed a lesion sub-totally. Post-operatively, the woman developed dysphagia and spinal accessory nerve weakness with a dropped right shoulder. She later underwent further surgery to remove some residual tumour, again sub-totally. Subsequent imaging has shown no evidence of tumour progression.
Claim The patient started a medical negligence claim against the GP, alleging she failed to properly investigate her complaint of headaches, which resulted in a delay in the diagnosis and treatment of her meningioma.
Expert opinions Opinions from six different experts can be summarised as follows:
• It was reasonable for the GP to diagnose tension headaches in the first instance.
• There is no record of the nature of the patient’ s headaches.
• The revelation that the plaintiff’ s headaches
QUESTIONS FOR OUR EXPERT
Dr Libby Harris is a GP in Sydney, NSW 1. Patients with persistent and / or recurrent headaches are commonly seen in general practice. What are the red flags for this presentation? One of the biggest challenges when faced with a patient with headache is to differentiate benign primary headaches from the more serious secondary headache caused by brain tumours, bleeding or infection. A good history is an invaluable tool to establish whether there is a pattern and should always be based on a sound knowledge of the underlying conditions that present with headache. Obvious red flags are first or worst headache ever, sudden onset, increased pain with exertion such as coughing or sneezing, postural link, systemic symptoms such as fever or weight loss, and neurological symptoms or signs.
2. What can GPs do to demonstrate their version of the events should be preferred? If we want our version of events to be preferred, we need to record the features of any headache in detail in the medical records in order to provide evidence that all the critical questions that determine a provisional diagnosis were asked and answered.
3. Why do decisions in many medical negligence claims seem to come down to who is the more credible witness— the patient or the doctor? In the legal system, the term“ causation” relates to connecting conduct with a resulting injury. For example, the GP’ s decision not to order imaging earlier created a delay in establishing the diagnosis which in turn resulted in the injury. In this case, the line of the argument breaks down because there is a lack of evidence that this delay altered the eventual outcome for the plaintiff.
had persisted for five years is of concern. This is at odds with the GP’ s medical records.
• Given a history of headaches, a prudent GP would have performed a thorough examination and arranged appropriate scanning.
• Had the diagnosis been made earlier, the tumour would not have been so large, would not have compressed the adjacent cranial nerves as much as it did and complete excision might have been possible.
• It is possible that the plaintiff suffered from intermittent tension-type headaches for some years and only later developed signs of the meningioma.
• The nature of the meningioma and its location were the primary reasons for the inability to complete surgical clearance, not its size.
• Had the diagnosis been made earlier, the decision to operate would have been a balance between the size of the lesion and the complaints. Immediate surgery would not necessarily have been the treatment of choice.
• There would have been no difference in treatment or eventual outcome had the plaintiff been operated on at an earlier date.
Outcome The matter was considered by the GP’ s MDO, which concluded the inconsistencies between her medical records and the patient’ s history weakened the defence and meant the claim of“ delay” would be difficult to defend. However, any claim that the delay was the cause of the patient’ s incapacity should be defended. The case was settled for a small sum inclusive of costs with terms not to be disclosed. ●
Dr Lilienthal is a GP and medicolegal adviser in Sydney, NSW.
Kracking the latest health hack risk
A KRACK vulnerability sounds like something that’ d send you straight to the ED. But it’ s actually a security risk in the most common wi-fi protocol, WPA2, revealed last month by Belgian researchers.
The discovery made news across the world. Here at home, the Australian Digital Health Agency( ADHA) issued a formal security alert about it.
KRACK refers to Key Installation Atta-C-K, an acronym so illogical it could almost have been the title of a clinical trial.
It requires a hacker to set up within range of a wi-fi, but not necessarily to be logged on, and to wait for somebody else to connect.
When that happens, the hacker can use a wireless program to hack the so-called‘ handshake’ between the other person’ s device and the network.
This allows the hacker to start intercepting, or even manipulating the data, sent via the wi-fi network.
In theory, this could see health information stolen, or enable hackers to demand ransoms in exchange for not messing with a health organisation’ s data.
It sounds scary— so what does the ADHA suggest can be done about it?
It’ s really simple. Update your software. Microsoft, Apple and Google have already released updates to block the KRACK vulnerability.
The problem is that large GP clinics and hospitals are often behind the times with computer updates, which is the reason they’ re often in hackers’ sights.
As an alternative, the ADHA recommends restricting the number of non-essential devices being used on the organisation’ s wi-fi, for example, stopping people from logging on with their personal phones or computers.
Online GP clinic wins innovation ward
Speaking of staying up-to-date, the online GP clinic Qoctor has won a gong for Best Tech Innovation at this year’ s finder. com. au awards.
Qoctor, formerly Dr Sicknote, made headlines this year for its virtual consultations that allow patients to secure specialist referrals and prescriptions based on online questionnaires.
Qoctor knocked over major telco Optus to claim the trophy.
CEO Dr Aifric Boylan said Qoctor was on the verge of an even greater honour— becoming a verb.
“ We want our customers to recommend their friends to‘ just Qoctor it’ meaning to find a quick, easy, trustworthy and reliable way to get better,” the Melbourne GP said.
It seems optimistic that Qoctor might enter the vernacular in the same way as Google— but who knows what the future holds.
www. australiandoctor. com. au 24 November 2017 | Australian Doctor | 13