November 2006. A MISSED DIAGNOSIS: Report written by Peter Wood, GP Devon, regarding my father's recent illness.
A previously extremely fit 80 year old man presented recently to me with 2 day history of an occipital headache. General examination was unremarkable and as it was possible that the pain was possibly abating a policy of watchful waiting was adopted. The pain did not settle and we met again 2 days later when the pain appeared to be more localised to the face and was worse with movement. Of note was that the patient’s wife drove him to the appointment because of diplopia. Blood tests were arranged and amoxicillin commenced for a presumptive diagnosis of sinusitis. The bloods revealed a raised CRP, and ESR, a nuetrophilia and mildly deranged LFTs. Over the next 3 days the patient was in contact with 3 other doctors initially for advice re fever and later continued pain: during this time the antibiotics were changed to erythromycin which appeared to produce considerable improvement. On review following these 3 days the pain appeared to be lessening but given the abnormal bloods I visited the following day when his general condition seemed even better.
Unfortunately as the antibiotics stopped, his pain increased again and he developed difficulty chewing, another doctor visited him and recommenced the erythromycin and arranged for further bloods.
I visited the following day: he had now lost vision in his right eye and his ESR was still raised – he was admitted with a diagnosis of Temporal Arteritis and commenced on high dose steroids. The visual acuity in his eye is now light perception only.
I present this case as an illustration of the difficulties I had in making this diagnosis and the catastrophic effects of missing it. There were clues: the odd presentation of an infrequent attender with a headache, the diplopia and the raised ESR even in the presence of other abnormalities and later the jaw claudication. Temporal Arteritis affects up to 50 per 100,000 people over 50: the history is not always classical and the apparent initial improvement serves to demonstrate this.
Odd headache; older patient; think Temporal Arteritis.
My family have Dr Wood’s permission to put this report on the internet in accordance with my father’s hopes that the condition might become better understood and more quickly recognised. What this report does not touch on is the terrible suffering that my father went through during the 3 weeks before a correct diagnosis was made. He hopes that by letting his story be told that others might be luckier and not have to suffer in the same way. Losing the sight in his right eye has been a devastating experience but he knows well that it could be much worse for a younger person whose career might be destroyed and family life severely affected.
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