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Taking your breath away

01 May 2008

Prompted by his wife, Mr F, a 40- year-old quantity surveyor, made an urgent appointment to see one of the doctors at his GP surgery one Friday afternoon. Mr and Mrs F saw GP, Dr T, at the practice.

Dr T checked back over Mr F’s clinical notes and discovered Mr F had only previously seen doctors for dietary advice regarding his obesity. There was no other significant past medical history; Mr F was not on any medication and had no known drug allergies.

Mrs F told Dr T that her husband had seemed very breathless for the last four days and that his “smoker’s cough” was getting worse. When Dr T asked, Mr F said that he had not experienced any chest pain or haemoptysis.

Dr T asked about Mr F’s “smoker’s cough” and discovered that Mr F had had a chronic cough for several years. Over the last few months, Mr F was unable to walk for long distances without getting “out of puff”. Mr F said he had smoked about 20 cigarettes a day since the age of 15, although Mrs F put the more recent figure at nearly 40 cigarettes a day.

Dr T noted Mr F’s blood pressure at 132/86 mmHg, pulse at 88 beats per minute, respiratory rate at 20 breaths per minute and temperature at 37.3°C. Dr T also recorded that breath sounds were quiet and that he heard right sided basal crackles.

Dr T told Mr F he thought he had a chest infection and it was likely he had chronic obstructive pulmonary disease (COPD). Dr T explained the condition to Mr F and offered smoking cessation advice. Dr T then prescribed Mr F a salbutamol inhaler and a week’s course of amoxicillin and arranged for him to have chest x-ray the following Monday.

Dr T advised Mr F to return to see him, or to call the out-of-hours doctors, if his symptoms weren’t improving, or if his condition deteriorated. On Saturday morning, Mr F’s shortness of breath worsened significantly and he developed severe pleuritic chest pain. He collapsed in his bedroom, and Mrs F dialled 999 for an ambulance. When the ambulance arrived at the house, the paramedics were unable to resuscitate Mr F and he was pronounced dead on arrival at the A&E Department.

Mr F’s postmortem examination revealed that both pulmonary arteries were occluded by recently impacted emboli and that DVT was present in both legs.

Mrs F and the rest of Mr F’s family began a claim against Dr T, alleging that he failed to consider a pulmonary embolism (PE).

Expert opinion

A GP expert was supportive of Dr T’s consultation with Mr F and said the notes Dr T made during the meeting were of a good standard. On the basis of the expert’s report, the claim was defended by MPS. The claim was discontinued by the family’s legal representatives soon afterwards.

Learning points

  • Dr T made a reasonable diagnosis based on the evidence before him, and ensured that there was adequate monitoring and review of Mr F. The fact that Mr F did not improve, and indeed that he had such a catastrophic outcome, does not make Dr T culpable.
  • The quality of the notes in this case helped to defend Dr T. The primary purpose of the notes is to help provide patient care. They should enable the reader to reconstruct the consultation performed. It is worth remembering that the reader of these notes could include: yourself or other doctors during future care of the patient; healthcare professionals; an expert witness (as in this case); a coroner, solicitor or judge; the patient themselves; or his or her family.
  • Shortness of breath (SOB) is a common presenting symptom in primary and secondary care. A past article in Casebook looked at the common difficulties and discussed the best way to assess this potentially dangerous symptom.1

1. Kavanagh S, SOB Story: A Brief Guide to Clinical Assessment of the Breathless Patient, Casebook 12 (4) 7–10 (2004)