A Clinical Risk Case Study- Importance of Considering Different Diagnoses After Appropriate History and Assessment

A Clinical Risk Case Study- Importance of Considering Different Diagnoses After Appropriate History and Assessment

Setting the Scene

The patient in this case, suffered from intermittent lower back pain and urinary symptoms, which ultimately required them to attend a local walk-in centre. Upon review by the Nurse Practitioner, they were told to consider weight loss and were prescribed an everyday painkiller for pain relief.

The following week the patient suffered from significant pain, numbness, difficulties urinating and suffered a collapse. Following this, they attended hospital where they were consequently diagnosed with cauda equina syndrome (CES), a medical emergency that compresses the nerves in the lower portion of the spinal canal.

The main learning points from this review stem from the following events:

  • When the Nurse Practitioner reviewed the patient, they did not carry out an adequate examination or take an account of the patient’s medical history to rule out the classic red-flag symptoms of CES, such as neurological injury, bowel dysfunction and saddle anaesthesia.

  • The Nurse Practitioner did not consider an alternative diagnosis, despite the patient presenting with symptoms suggestive of CES.

  • As the Nurse Practitioner did not consider an alternative diagnosis, they did not communicate the signs of CES to the patient or advise them to seek further medical assistance if their symptoms did not improve with pain relief.

Recommendations to Prevent Incident Recurrence and Improve Patient Safety

TMLEP’s recommendations to reduce recurrence and enhance patient safety are as follows:

  • Ensure that when a patient is reviewed upon arrival at any walk-in centre, hospital or GP Practice, that a detailed medical history is obtained (as per NICE guidelines) and that appropriate assessments are carried out to rule out differential diagnoses. If CES is considered, then examinations should include a neurovascular assessment of lower limbs and a straight leg raise. If the patient is exhibiting signs suggestive of CES, then they need to be referred to the relevant medical teams; in this case the local A&E department.

  • When a patient is discharged, it is recommended to provide appropriate advice to the patient in relation to seeking further medical assistance. If informational leaflets or documents are provided, then the practitioner should explain the information to the patient to ensure that they completely understand the red-flag symptoms and when to seek further medical assistance.

To Summarise

This is a case of a patient who suffered from lower back pain in addition to difficulties urinating who was subsequently diagnosed with CES.

TMLEP would like to highlight the importance of taking appropriate medical histories and carrying out assessments, looking for red-flag symptoms to rule out differential diagnoses.

In this case, CES should have been considered due to symptoms of lower back pain, urinary issues and numbness to the perineal area. If a patient presents with these symptoms, then further assessments to examine the patient’s lower limb motor function should be undertaken.

Lastly, it is imperative that practitioners communicate important information provided in leaflets to patients so that they are aware of red-flag symptoms and advised when to seek further medical help.

References

  • NICE (2018) Sciatica (lumbar radiculopathy) https://cks.nice.org.uk/sciatica-lumbar-radiculopathy#!diagnosissub:1
  • WHITE, p (20180 Caude Equina Syndrome: changes to NICE CKS red flags. https://www.gponline.com/cauda-equina-syndrome-changes-nice-cks-red-flags/musculoskeletal-disorders/article/1464440
  • Co-written by The TMLEP Clinical Risk and Patient Safety Publishing Group and Ms Dorthe Swaby-Larsen, Independent Nurse Practitioner. . (2020). A Clinical Risk Case Study- Importance of considering different diagnoses after appropriate history and assessment. TMLEP Clinical Risk Case Studies. 4 (1), 1.

Important Note

This article is intended to raise awareness to clinical risk issues in an effort to reduce incidence recurrence and improve patient safety. This is not intended to be relied upon as advice. Facts have been altered to ensure this case is non-identifiable, albeit clinical learning points remain applicable. To request an independent clinical review, please contact admin@tmlep.com or call +44 (0) 203 355 9796.