Unforeseen consequencesBMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7223.1471 (Published 04 December 1999) Cite this as: BMJ 1999;319:1471
It was not long after I had arrived to take over a singlehanded practice in a rural part of Ireland that I first met Jean. I was struck by her big hands, jutting chin, and rather waxy facial features. The fact that she had hypertension and diabetes lent support tomy clinical impression of acromegaly and that this had gone unnoticed in over three yearsof attendance at the hospital medical outpatient department added to the glow of satisfaction when the diagnosis was confirmed by an endocrinologist.
Jean was glad to have a diagnosis but was nervous of the prospect of surgery when a computed tomogram showed the pituitary tumour responsible. Her daughter had died some yearsearlier of a brain tumour and neurosurgery was linked in her mind with this. Thanks to a skilled neurosurgeon (the same man who had operated on her daughter) everything went welland Jean had her tumour resected.
Six months later at routine follow up, a scan raised the possibility of a middle cerebral artery aneurysm, an unrelated condition which might never have been diagnosed normally. An angiograph confirmed bilateral middle cerebral artery aneurysms and Jean was admitted to have them clipped. The right artery was clipped but she developed a hemiparesis which resolved fairly quickly. It was decided to readmit her at a later date to clip the left side.
The experience frightened Jean and she was dubious about further surgery. I spoke withthe neurosurgeon who said that about one patient in 20 would develop spasm following surgery and this could give a stroke-like effect. However, he thought that the risk of surgery was less than the risk of an untreated aneurysm. Jean made a pilgrimage to Lourdes.
Two months later Jean decided to go ahead with the operation. Postoperative recovery was slow and unfortunately she developed another hemiparesis dysphasia and became completely dependent on nursing staff.
Now three yeas on, Jean is in a nursing home. Her hemiparesis has resolved considerably, but she is unable to speak and seems to have a global dysphasia. Her husband, Michael, attends me regularly. He lives alone about 15 miles from the nursing home and visits Jeannearly every day. He blames no one for what has happened. He accepts that the doctors made their decisions in good faith and after careful consideration.
If I come across another patient with signs and symptoms like Jean I would undoubtedlyrefer that patient to an endocrinologist. However, I feel sad and humbled by Michael's loneliness and cannot help wondering whether or not Jean might still be living with him albeit unaware of her acromegaly and dilated middle cerebral arteries, were it not for the arrival of the new doctor and his clever diagnosis.
We welcome articles of up to 600 words on topics such as A memorable patient, A paper that changed my practice, My most unfortunate mistake, or any other piece conveying instruction, pathos, or humour. If possible the article should be supplied ona disk. Permission is needed from the patient or a relative if an identifiable patient isreferred to. We also welcome contributions for “Endpieces,” consisting of quotations of up to 80 words (but most are considerably shorter) from any source, ancient or modern, which have appealed to the reader.
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