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Connect issue 12

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Dr Mark Woodrow In identifying a patient's medical issue, the most common conditions are often the ones considered first. Unfortunately we often see many GP cases where a rare condition has not been diagnosed and a poor outcome has ensued. This case is a good reminder that rare conditions should still be kept in mind and ruled out. Failure to identify A patient* attended his general practitioner (GP) with back pain as a consequence of a work injury. He was treated with analgesia and recommended physiotherapy. The patient presented to the GP twice more over the next few days with increasing pain and sciatica, requiring stronger analgesia, and then visited an after-hours clinic. On each occasion the patient was treated with escalating analgesia. A few days after his latest visit, he presented to an emergency department with established urinary retention. Despite undergoing decompressive surgery for a large prolapsed lumbar disc, the patient had residual bladder dysfunction and leg "It seems you have…" Missed diagnosis Case learnings • Consider cauda equina syndrome (CES) in all patients with back pain. Enquire about bowel, bladder and sexual dysfunction, as well as weakness and sensory disturbance. Examine the patient for power, sensation and reflexes, and consider testing perineal sensation, anal tone and bulbocavernosus reflex. • If CES is suspected, refer urgently for investigation by MRI and specialist management. • Begin discussion about potential outcomes at an early stage and include this in the consent for treatment. • If the patient is discharged, warn about 'red flags' and the need for further urgent review. • Keep contemporaneous and comprehensive notes. In particular, documented negative findings of no urinary or bowel dysfunction, no altered perineal sensation, and normal reflexes and peripheral sensation are powerful defences against a claim. weakness. The patient was unable to work, required a wheelchair and assistance with daily living. The patient lodged a civil claim for compensation against all treating doctors, claiming they were negligent in failing to diagnose cauda equina syndrome (CES) and delayed treatment. Recognising cauda equina syndrome CES is a rare presentation of the common complaint of back pain. Cardinal clinical features include: • bladder dysfunction • altered perineal and genital sensation • severe back pain and sciatica. Bowel and sexual dysfunction, and weakness and altered sensation in the legs are also common. Prompt identification and investigation of CES, followed by urgent decompressive surgery within 24-48 hours, is critical. Intuitively, earlier decompression leads to a better outcome. However, a poor outcome can occur even in appropriately managed cases, often leading to dissatisfaction and legal consequences. It is important for doctors to consider and recognise CES and to treat the condition, rather than just the symptoms of pain, constipation and bladder difficulties. Useful resources avant.org.au — Factsheet • Missed or delayed diagnosis *This case is based on our claims experience. Any relation to actual people is purely coincidental. Avant author Dr Mark Woodrow MBBS, MBA, GDAppLaw, GCArts, GCertEM (ACEM) Claims Manager and Medical Advisor, QLD Prompt diagnosis and referral are essential Delay in diagnosis is common, with delayed presentation and failure to consider CES in patients with back pain, and to enquire about cardinal features. These delays are also associated with a failure to examine the patient appropriately and confirm the diagnosis with urgent appropriate imaging, preferably MRI. Delayed referral and transfer to specialist care, delays in deciding and proceeding to surgery, and failure to inform the patient of indications to seek urgent medical review, represent other areas of medico-legal exposure. Case outcome In this case, it was probable that CES was not present when the patient was examined and the subsequent delay to presentation when urinary symptoms developed meant that the outcome was inevitable. Unfortunately, the GP's poor medical notes implied cursory assessment on each occasion, and a failure to inform the patient of indications for urgent review and delays to surgery meant a settlement had to be reached with the patient. 10 Connect | Issue 12 | May 2019

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