Pseudo–Brain Tumor Impairs Woman’s Vision

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

Pseudo–Brain Tumor Impairs Woman’s Vision
In Kentucky, a 22-year-old woman went to the ED with a 10-day history of painful headache. According to the patient, she told the defendant emergency physician, Dr. W., that she had been having vision problems. Dr. W. made a diagnosis of stress and advised the patient to rest. When the woman’s condition had not improved a few weeks later, she visited her primary care physician, Dr. C. She was given a diagnosis of migraine.

During the succeeding month, the patient’s vision worsened. Ultimately, she was diagnosed with a pseudo–brain tumor. Despite aggressive intervention, she experienced significant vision loss.

The plaintiff alleged negligence in her physicians’ failure to make a timely diagnosis. She claimed that CT or fundoscopy should have been performed in the ED and also alleged negligence in Dr. C.’s diagnosis of migraine.

Dr. C. settled prior to trial. Dr. W. claimed that the plaintiff’s presentation and complaints made his treatment reasonable and that in the absence of trauma to the eye, an emergency physician would not normally check for visual acuity. The defendant also contended that the plaintiff’s condition was rare and would have been difficult to diagnose. The defendant also blamed the plaintiff for her delay in seeking follow-up care.

OUTCOME
A jury found the defendant emergency physician 30% at fault, the settling physician 50% at fault, and the plaintiff 20% at fault. The verdict totaled $685,000, including a $205,500 judgment against Dr. W.

COMMENT
Primary care providers see nontraumatic headaches every day. Though usually self-limiting and benign, headaches can also be the only symptom of a serious or fatal condition, including subarachnoid hemorrhage (SAH), meningitis, or giant-cell arteritis. Additionally problematic is the patient with previous headache who presents with headache of a different character or new symptomatology.

Pseudotumor cerebri, or idiopathic intracranial hypertension (IIH), presents subtly but may end with progressive optic atrophy and blindness. Despite its elusive etiology, IIH develops more commonly among women of childbearing age with an elevated BMI. Its nonspecific signs and symptoms include headache and vomiting. More specific clues include pulsatile tinnitus and horizontal diplopia. Progressive loss of peripheral vision, transient visual dimming or blackout in one or both eyes, and blurring and distortion of central vision can occur.

Papilledema is generally present, with venous engorgement, loss of venous pulsation, hemorrhages over or adjacent to the optic disc, elevation or blurring of disc margins, and retinal striae. Performing fundoscopic examination correctly can be challenging, and papilledema can be missed. For those who haven’t seen clinical evidence of papilledema in some time, reviewing retinal findings is encouraged.

Real-world challenges can hinder examination: well-meaning staff who dim the lights to near-blackout conditions; inaccessibility to the patient cocooned in blankets; the chronic pain patient who resists examination, insisting, “I’m just here for my pain medicine.” Don’t let impediments like these hinder your examination.

The physical exam must include neurologic testing—cranial nerve and fundoscopic examination, ocular motility, and visual field testing. It is important to recognize and validate the patient’s pain, but don’t skimp on the exam to spare them discomfort.

To rule out intraocular pathology, visual acuity should be tested. Acuity testing provides objective data and may reveal visual symptoms, such as scotoma or blurred vision. Visual acuity should be considered a vital sign for patients presenting with primary ocular complaints or headache.

Neuroimaging is generally indicated in headache with new abnormal neurologic findings (eg, altered metal status or cognitive function or focal deficit); a new sudden-onset severe headache; or a new headache in any HIV-positive patient. When SAH is a possibility (“thunderclap” headache or “worst in life” with swift intensity), neuroimaging, followed by cerebrospinal fluid analysis and observation, is required.

In this case, fundoscopy and visual field testing were warranted, and acuity testing would be reasonable. The patient’s headache was new, and if the symptoms were severe or if papilledema or visual field defects were discovered, neuroimaging was indicated.

Using “stress” as a diagnostic term may later be brandished by a plaintiff’s attorney as a sign that a patient with organic disease was not taken seriously.

Lastly, patients with a diagnosis of tension headache should be instructed to return if other symptoms arise or the headache changes or worsens—all documented in the patient’s record.—DML           

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

Pseudo–Brain Tumor Impairs Woman’s Vision
In Kentucky, a 22-year-old woman went to the ED with a 10-day history of painful headache. According to the patient, she told the defendant emergency physician, Dr. W., that she had been having vision problems. Dr. W. made a diagnosis of stress and advised the patient to rest. When the woman’s condition had not improved a few weeks later, she visited her primary care physician, Dr. C. She was given a diagnosis of migraine.

During the succeeding month, the patient’s vision worsened. Ultimately, she was diagnosed with a pseudo–brain tumor. Despite aggressive intervention, she experienced significant vision loss.

The plaintiff alleged negligence in her physicians’ failure to make a timely diagnosis. She claimed that CT or fundoscopy should have been performed in the ED and also alleged negligence in Dr. C.’s diagnosis of migraine.

Dr. C. settled prior to trial. Dr. W. claimed that the plaintiff’s presentation and complaints made his treatment reasonable and that in the absence of trauma to the eye, an emergency physician would not normally check for visual acuity. The defendant also contended that the plaintiff’s condition was rare and would have been difficult to diagnose. The defendant also blamed the plaintiff for her delay in seeking follow-up care.

OUTCOME
A jury found the defendant emergency physician 30% at fault, the settling physician 50% at fault, and the plaintiff 20% at fault. The verdict totaled $685,000, including a $205,500 judgment against Dr. W.

COMMENT
Primary care providers see nontraumatic headaches every day. Though usually self-limiting and benign, headaches can also be the only symptom of a serious or fatal condition, including subarachnoid hemorrhage (SAH), meningitis, or giant-cell arteritis. Additionally problematic is the patient with previous headache who presents with headache of a different character or new symptomatology.

Pseudotumor cerebri, or idiopathic intracranial hypertension (IIH), presents subtly but may end with progressive optic atrophy and blindness. Despite its elusive etiology, IIH develops more commonly among women of childbearing age with an elevated BMI. Its nonspecific signs and symptoms include headache and vomiting. More specific clues include pulsatile tinnitus and horizontal diplopia. Progressive loss of peripheral vision, transient visual dimming or blackout in one or both eyes, and blurring and distortion of central vision can occur.

Papilledema is generally present, with venous engorgement, loss of venous pulsation, hemorrhages over or adjacent to the optic disc, elevation or blurring of disc margins, and retinal striae. Performing fundoscopic examination correctly can be challenging, and papilledema can be missed. For those who haven’t seen clinical evidence of papilledema in some time, reviewing retinal findings is encouraged.

Real-world challenges can hinder examination: well-meaning staff who dim the lights to near-blackout conditions; inaccessibility to the patient cocooned in blankets; the chronic pain patient who resists examination, insisting, “I’m just here for my pain medicine.” Don’t let impediments like these hinder your examination.

The physical exam must include neurologic testing—cranial nerve and fundoscopic examination, ocular motility, and visual field testing. It is important to recognize and validate the patient’s pain, but don’t skimp on the exam to spare them discomfort.

To rule out intraocular pathology, visual acuity should be tested. Acuity testing provides objective data and may reveal visual symptoms, such as scotoma or blurred vision. Visual acuity should be considered a vital sign for patients presenting with primary ocular complaints or headache.

Neuroimaging is generally indicated in headache with new abnormal neurologic findings (eg, altered metal status or cognitive function or focal deficit); a new sudden-onset severe headache; or a new headache in any HIV-positive patient. When SAH is a possibility (“thunderclap” headache or “worst in life” with swift intensity), neuroimaging, followed by cerebrospinal fluid analysis and observation, is required.

In this case, fundoscopy and visual field testing were warranted, and acuity testing would be reasonable. The patient’s headache was new, and if the symptoms were severe or if papilledema or visual field defects were discovered, neuroimaging was indicated.

Using “stress” as a diagnostic term may later be brandished by a plaintiff’s attorney as a sign that a patient with organic disease was not taken seriously.

Lastly, patients with a diagnosis of tension headache should be instructed to return if other symptoms arise or the headache changes or worsens—all documented in the patient’s record.—DML           

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

Pseudo–Brain Tumor Impairs Woman’s Vision
In Kentucky, a 22-year-old woman went to the ED with a 10-day history of painful headache. According to the patient, she told the defendant emergency physician, Dr. W., that she had been having vision problems. Dr. W. made a diagnosis of stress and advised the patient to rest. When the woman’s condition had not improved a few weeks later, she visited her primary care physician, Dr. C. She was given a diagnosis of migraine.

During the succeeding month, the patient’s vision worsened. Ultimately, she was diagnosed with a pseudo–brain tumor. Despite aggressive intervention, she experienced significant vision loss.

The plaintiff alleged negligence in her physicians’ failure to make a timely diagnosis. She claimed that CT or fundoscopy should have been performed in the ED and also alleged negligence in Dr. C.’s diagnosis of migraine.

Dr. C. settled prior to trial. Dr. W. claimed that the plaintiff’s presentation and complaints made his treatment reasonable and that in the absence of trauma to the eye, an emergency physician would not normally check for visual acuity. The defendant also contended that the plaintiff’s condition was rare and would have been difficult to diagnose. The defendant also blamed the plaintiff for her delay in seeking follow-up care.

OUTCOME
A jury found the defendant emergency physician 30% at fault, the settling physician 50% at fault, and the plaintiff 20% at fault. The verdict totaled $685,000, including a $205,500 judgment against Dr. W.

COMMENT
Primary care providers see nontraumatic headaches every day. Though usually self-limiting and benign, headaches can also be the only symptom of a serious or fatal condition, including subarachnoid hemorrhage (SAH), meningitis, or giant-cell arteritis. Additionally problematic is the patient with previous headache who presents with headache of a different character or new symptomatology.

Pseudotumor cerebri, or idiopathic intracranial hypertension (IIH), presents subtly but may end with progressive optic atrophy and blindness. Despite its elusive etiology, IIH develops more commonly among women of childbearing age with an elevated BMI. Its nonspecific signs and symptoms include headache and vomiting. More specific clues include pulsatile tinnitus and horizontal diplopia. Progressive loss of peripheral vision, transient visual dimming or blackout in one or both eyes, and blurring and distortion of central vision can occur.

Papilledema is generally present, with venous engorgement, loss of venous pulsation, hemorrhages over or adjacent to the optic disc, elevation or blurring of disc margins, and retinal striae. Performing fundoscopic examination correctly can be challenging, and papilledema can be missed. For those who haven’t seen clinical evidence of papilledema in some time, reviewing retinal findings is encouraged.

Real-world challenges can hinder examination: well-meaning staff who dim the lights to near-blackout conditions; inaccessibility to the patient cocooned in blankets; the chronic pain patient who resists examination, insisting, “I’m just here for my pain medicine.” Don’t let impediments like these hinder your examination.

The physical exam must include neurologic testing—cranial nerve and fundoscopic examination, ocular motility, and visual field testing. It is important to recognize and validate the patient’s pain, but don’t skimp on the exam to spare them discomfort.

To rule out intraocular pathology, visual acuity should be tested. Acuity testing provides objective data and may reveal visual symptoms, such as scotoma or blurred vision. Visual acuity should be considered a vital sign for patients presenting with primary ocular complaints or headache.

Neuroimaging is generally indicated in headache with new abnormal neurologic findings (eg, altered metal status or cognitive function or focal deficit); a new sudden-onset severe headache; or a new headache in any HIV-positive patient. When SAH is a possibility (“thunderclap” headache or “worst in life” with swift intensity), neuroimaging, followed by cerebrospinal fluid analysis and observation, is required.

In this case, fundoscopy and visual field testing were warranted, and acuity testing would be reasonable. The patient’s headache was new, and if the symptoms were severe or if papilledema or visual field defects were discovered, neuroimaging was indicated.

Using “stress” as a diagnostic term may later be brandished by a plaintiff’s attorney as a sign that a patient with organic disease was not taken seriously.

Lastly, patients with a diagnosis of tension headache should be instructed to return if other symptoms arise or the headache changes or worsens—all documented in the patient’s record.—DML