Abstract
Case history
A 56-year-old gentleman presented via telephone triage with a 3-week history of morning headache. He had no significant comorbidities. He described a unilateral aching pain extending from his right eye to the occiput. The GP also elicited poor sleep, apnoeic episodes and snoring. Obstructive sleep apnoea was the provisional diagnosis and the patient was booked for review with a GP registrar.
At review the pain was noted to be worse in the mornings and associated with increased fatigue. The patient commented: ‘I can fall asleep at a moment’s notice’. His partner reported a decline in mood and more aggressive behaviour. There were no signs of focal neurology, no nausea or vomiting and examination was unremarkable. A sleep apnoea-focused history was taken and the patient reassured that the headache was benign. Safety netting was documented as, ‘worsening advice given’. The patient sought further advice over the phone 10 days later and reported worsening pain and mild photophobia. The diagnosis of sleep apnoea was reaffirmed and the patient was advised to seek help if symptoms deteriorated, but specific safety netting advice was not documented.
After a further two weeks the patient presented with vomiting, confusion and drowsiness. Nystagmus was noted and he was sent to the emergency department for a suspected space-occupying lesion. A computerised tomography scan showed a right frontal tumour, in keeping with a glioblastoma and the patient was commenced on dexamethasone, providing significant symptomatic relief. The diagnosis was confirmed by a subsequent magnetic resonance imaging and biopsy, following which chemotherapy and radiotherapy were organised.
Discussion
Glioblastomas (GBMs) are the most common form of malignant central nervous system tumour with approximately 4000 cases per year in the UK. They display a male preponderance, a median age of presentation of 60 years and a median survival rate from diagnosis of 15 months, with a 5-year survival rate below 7% (Sehmer et al., 2014).
Other than ionising radiation, causative factors are unclear, although there may be underlying genetic susceptibilities. The presentation of a GBM is variable. Focal neurological features may be evident; however, larger tumours arising from the frontal/temporal lobes and the corpus collosum often present with fatigue, confusion, memory loss, mood and personality change. Treatment is with a combination of radiotherapy and chemotherapy, but is not curative. It remains one of the most lethal cancer diagnoses (Stupp et al., 2014).
The National Institute for Health and Care Excellence (NICE) guidance on headaches (NICE, 2012) lists signs that warrant consideration of investigation. These include neurological signs, fevers, trauma, sudden onset and visual changes. However, more subtle changes such as mood and personality change, changes in posture, increased sleep and mild confusion may warn of a space-occupying lesion. Symptoms should be evaluated where parallel diagnoses coexist through focused history taking. In this case, how long had the patient experienced sleep apnoea symptoms? Over what period of time did the drowsiness present, and was this in keeping with the timeframe of the headache, sleep apnoea or mood? Did his mood and personality change occur more recently and how did it relate to the pattern of the headache and sleep apnoea? Evolving symptoms should lead to reassessment, which may lead to earlier imaging and thus, symptomatic relief.
Safety netting advice should include detail of the signs and symptoms of which to be aware, actions to take and specific follow up arranged. This is in line with the RCGP curriculum where GPs are expected to ‘manage risk effectively in consultations, safety netting appropriately’ while ‘providing appropriate documentation for each patient contact’. This is good practice and also has potential medicolegal impact.
In summary, GBMs can have a diverse set of presentations. More elusive symptoms such as mood and personality change can be features of a space-occupying lesion and the clinician needs to explore and explain symptoms rationally. Documentation of the history and advice needs to be suitably clear, encompassing appropriate management plans. This not only facilitates good care, but also provides robust evidence of good care.
