A 58-year-old female with a history of headaches, depression, anxiety and anorexia nervosa, sought out an internist after hearing him give a talk on migraine headaches. She had suffered from headaches since age 21, with a postmenopausal remission. Now, however, her headaches were a daily occurrence. During her initial visit with the internist, the patient described a series of recent losses in her life, including a break-up with a long-time boyfriend. The headaches were affecting her mood and her ability to sleep. She was taking Doxepin for insomnia & depression.

Her physical exam, which included a brief neurological evaluation, was normal. The internist attributed her headaches to the recent stress in her life, and diagnosed her with 1) transformed migraine headaches, 2) chronic dysthymia, and 3) chronic insomnia. After the patient started on Depakote as a prophylactic for her headaches, she experienced some short-lived relief.

During the following five months, the pain returned in full, dosages of the initial medications were adjusted, exams were normal, and the internist eventually switched the medication to Zoloft and Ambien. When he referred the patient to counseling, she did not return.

The patient then presented to her PCP with complaints of daily migraine headaches. Her PCP attributed her headaches to stress and her caffeine intake. She was given Tylenol, Klonopin, and aspirin.

A year later, the patient again saw her PCP for the headaches, which were now waking her up. She patient was started on Buspar. Counseling was again recommended, which the patient soon started.

Within four months—two years after her first complaint to the internist—the patient self-referred to a neurologist for evaluation of her headaches. Her neurological exam was normal. The neurologist diagnosed rebound headaches and advised the patient to alternate between Tylenol and Ibuprofen.

Two weeks after this neurology appointment, the patient was found slumped over the steering wheel at a red light. A CT scan at the hospital revealed a large, right temporal parenchymal hematoma. There was also a right subdural hematoma. The patient had fixed pupils and continued to be unresponsive. CTA revealed multiple aneurysms, (the largest in the middle cerebral artery). After emergency surgery, the patient developed asystole for 30 minutes. The family declared her a DNR, and the patient was pronounced dead.

1. Both the internist and the PCP treated the patient’s condition as chronic, and no diagnostic studies or referrals were made. When the patient self-referred to a neurologist, he chose not to order any diagnostic studies either.
   Patients with chronic conditions can easily present with a new acute condition masked by characteristics of the earlier diagnosis. Providers who rely on a previous clinician’s diagnosis, without an independent history and physical, compromise their ability to establish a differential diagnosis and evaluate medical risk factors. Revisiting the differential diagnosis in the face of unresolved symptoms is essential to avoiding “tunnel vision” or a too-narrow diagnostic focus that can lead to diagnostic delay. Identifying other possible causes for a patient’s symptoms may prompt the ordering of further diagnostic studies that help providers home in on the true cause.
   
   
2. The three providers in this case did not communicate about this patient’s care: previous records were not obtained; follow-up was not attempted.
   For a patient to receive the best care available, it has to be coordinated. It is especially important to make sure that the patient is following up on any recommendations (and, if not, why). PCPs traditionally handle that role for their patients, but all providers are obliged to share critical information. Each clinician can help ensure appropriate follow up and coordination by verifying with the others who will be following a particular problem. Mental health referrals don’t necessarily signal the end of physical symptoms or elimination of physical causes in the differential. Although counseling may be an appropriate recommendation in the treatment plan, a clinical explanation should stay in the differential diagnosis until symptoms resolve.
   
   

1. Lack of communication among providers, including review of previous documentation resulted in a missed opportunity to evaluate previous treatment modalities and the patient’s response.
   If a patient seeks care from numerous providers, it is generally considered a red flag. It could also be a signal for physicians to carefully listen to the patient’s perspective regarding his/her unresolved problem. For a patient who is not improving after standard treatment modalities, and who complains of worsening symptoms, a prudent course would be additional testing or referral to a specialist for an independent evaluation. A reliable practice-based system that tracks patients who do not return to the office when expected can trigger an effort to find out why, and whether or not their problem has been resolved.
   
   

1. This case has many of the elements that can lead to a claim: a death in an otherwise healthy woman, and multiple providers all failing to recognize a problem as possibly non-psychological.
   A focus group believed strongly that the doctors should have reviewed the patient’s prior records and should have ordered some imaging. Jurors and arbitrators empathize with patients whose complaints seem to fall on deaf ears.