Case 4 A dizzy man

Bernard was 60 years old when he was visited by an Out of Hours general practitioner, Dr Carter, on a weekend evening. He stated that he woke that day, turned over in bed and felt that the room was spinning. He had vomited twice in the bed. During the morning he felt unsteady on his feet and had become very anxious because he lived on his own and was unsure how he would cope. He had felt nonspecifically unwell for a couple of days with a sore throat and malaise. He had made himself some hot lemon with whisky that evening but had been unable to drink it. He had had a coronary angioplasty and stent two years earlier and was on a statin, aspirin and a beta blocker.

What would you do now?

Dr Carter established that the vertigo was intermittently so severe that Bernard had difficulty standing. He had difficulty walking but managed if he kept his head still. He felt comfortable once he was sitting still or lying down. On direct questioning he had a slight headache, was not aware of any weakness, had a sore throat and a hoarse voice.

What would be your differential diagnosis and how would you discriminate between them?

Dr Carter noted that the man looked well but anxious, had a temperature of 37.4 °C, pulse 64/min regular and a BP 174/92 mmHg. Dr Carter suggested doing a Hallpike test but Bernard was anxious about provoking the vertigo. Dr Carter recorded that Bernard probably had a viral labyrinthitis and pharyngitis and prescribed stemetil and paracetamol.

Bernard’s son visited him the next day and found his father was unwell with a high fever and a severe cough. He took him to the local ED department where a chest X-ray demonstrated a pneumonia. He was admitted onto a general medical ward. The following day one of the nurses noted that Bernard was choking when drinking fluids. Further assessment by the medical registrar demonstrated that the man had a hoarse voice, a weak cough and that palatal movements were asymmetric on saying ‘aah’ (the uvula moving to the left). Bernard regurgitated water on drinking. Light touch was subjectively different on the right cheek to the left, there was a right Horner’s syndrome, sustained nystagmus and he could not walk unaided. A cranial MRI scan demonstrated patchy infarction of the right lateral medulla and inferior cerebellum. The diagnosis was made of an aspiration pneumonia secondary to a brainstem stroke. Bernard was unwell and dehydrated and his neurological deficit extended. A further MRI showed more extensive dorsolateral medullary infarction. Bernard made only a partial recovery.

Bernard sued Dr Carter for failing to consider the possibility of a stroke and for omitting to check for dysphagia, and sued the hospital for initially missing the stroke and treating him for pneumonia.

Do you think his claim will succeed?

Expert opinion

Vertigo is a difficult presentation for a general practitioner and requires careful assessment. It is relatively common. A full time general practitioner can expect to see 10–20 cases of acute vertigo per year (McCormick et al., 1995). The vast majority will be due to malfunctions of the labyrinth – vertigo caused by a peripheral lesion. Roughly 40% will be due to benign paroxysmal positional vertigo (BPPV), 40% will be due to acute vestibular neuritis and a significant proportion of the rest may have vestibular migraine (Barraclough & Bronstein, 2009). However, a critical aspect of the general practitioner’s assessment must be to distinguish the tiny number of cases of vertigo due to brainstem lesions (mostly brainstem strokes) from the large number of peripheral causes of vertigo.

In this case there were a number of features that should have alerted Dr Carter to consider the possibility of a central (brain stem) cause rather than a peripheral cause. At 60 Bernard was in the age range where cerebrovascular events are not uncommon. It was a concern that he had difficulty walking and drinking and that his voice was hoarse. The latter were suggestive of dysphagia and dysphonia.

Dr Carter should have established a few additional features. It was not clear from the history if the vertigo was positional or sustained. He should have seen if the man could drink a glass of water. If he could drink then significant dysphagia was unlikely. He should have seen him walk and checked that there was no facial, hand or arm weakness. All these are quite easy tests and if normal, make a brainstem stroke unlikely. If the tests were abnormal the man should have been referred immediately into hospital with a possible stroke (NICE, July 2008, Clinical guidelines on stroke).

Because structures in the brainstem are closely packed together, vertigo in the absence of any other cranial nerve features (such as diplopia, facial weakness, facial numbness, dysphagia, dysphonia) or long tract symptoms (such as weakness or numbness of the limbs) is unlikely to be due to a central cause. Fewer than 1% of 407 patients with posterior circulation strokes in the New England Medical Centre Posterior Circulation Registry (NEMC-PCR) presented with a single isolated symptom (Caplan et al., 2004). Another study of 1666 patients aged over 44 presenting to a US emergency department with ‘dizziness’ found 53 (3.6%) were due to a stroke or a TIA. In patients with ‘dizziness’ without other symptoms or signs only 0.7% had had a stroke or TIA (Kerber et al., 2006).

Dr Carter attempted to make a positive diagnosis but was negligent in not checking that there were no other neurological signs – particularly dysphagia, dysphonia, palatal weakness, facial weakness or numbness or ataxia.

Legal comment

The expert says it was negligent of Dr Carter not to have checked Bernard for neurological signs. If he had done so, he would have probably found abnormalities which would have led him to admit Bernard to hospital.

As it was, in the hours before his son came to visit, it seems that Bernard developed an aspiration pneumonia because of his dysphagia. That pneumonia may have worsened the neurological deficit which will now affect Bernard for the rest of his life. He has sued both the GP and the hospital.

As well as looking at breach of duty the lawyers for each will take expert opinions on the cause of the additional neurological deficit. Maybe after all, despite any failings by either party, that deficit is entirely unrelated. It may have been simply a continuation of the brain stem infarction. In that case, Bernard’s claim will fail.

But if Bernard’s worse outcome is probably the result of the aspiration pneumonia, then Dr Carter’s MDO will have to pay Bernard compensation to reflect his additional disabilities.

The MDO may seek a contribution from the hospital. If there is expert medical evidence to suggest that it too was negligent then there is likely to be negotiation between the lawyers for those two defendants.

Bernard’s compensation will be assessed according to a comparison between the likely outcome if he had been properly managed, and the actual outcome. The costs of any additional care now required because of the additional deficit will be calculated by reference to Bernard’s life expectancy.

Stay updated, free articles. Join our Telegram channel

Join