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Symptoms that don’t add up

01 January 2012

Mr B was a 30-year-old garage manager who had just returned from a long trip abroad with his wife. After the flight he developed some chest tightness. This showed no signs of improvement after ten days so Mr B made an appointment with his GP, Dr W.

Dr W took a brief history and documented only that he had no cough or sputum. He did not ask about the character, site or radiation of the chest pain, or ask about recent long flights or family history of thrombosis.

Despite documenting “no cough, sputum and examination of the chest normal”, he diagnosed a chest infection but also documented that he had queried asthma. Dr W prescribed seven days of amoxicillin and arranged a chest x-ray and an ECG.

Over the next few days Mr B’s chest pain persisted. It was retrosternal and he found himself taking shallow breaths because the pain was worse on inspiration. He walked down to the GP surgery and was quite short of breath just walking down the road.

Dr W reviewed him the same day and his examination notes stated “no pain or swelling in the legs”. He looked at the chest x-ray report and the ECG and noted them to be normal, although the ECG had showed a sinus tachycardia. Again there was no record of him taking a detailed history of the chest pain or breathlessness. Dr W changed the antibiotics to erythromycin and added in gaviscon to ease the retrosternal chest pain, which he thought was dyspeptic in nature.

The next day, Mr B became very anxious because he was now breathless just walking around at home. His wife was worried so made him another appointment to see his GP. Dr W documented that he was anxious but that examination was normal other than a slightly raised blood pressure and heart rate, which he put down to anxiety. He prescribed some diazepam for his “nerves”.

Almost three weeks after the chest tightness started, Mr B became acutely short of breath and dizzy, then collapsed at home. His wife called emergency services but despite all attempts by the paramedics he was pronounced dead on arrival at hospital. The postmortem showed bilateral pulmonary thromboemboli.

Mr B’s wife was devastated and made a claim against Dr W. The case was settled for a substantial sum.

Learning points

  • For patients who keep coming back with the same complaint, it is always wise to review the initial diagnosis. A patient who is not responding to treatment as expected might need to have the whole picture revisited with a fresh pair of eyes. See the article “Tunnel vision”, in Casebook 19(2).
  • It is important to consider more unusual diagnoses. Although a pulmonary thromboembolus is a relatively rare diagnosis in a healthy young man, it does happen. Unless you think about it you’ll miss it.
  • It should be remembered that not all pulmonary emboli are preceded by signs of a clear DVT.
  • When considering the differential diagnosis of breathlessness, it is useful to consider whether it is acute or chronic and to decide whether it is pulmonary, cardiac or physiological in nature.
  • Great care must be taken when diagnosing anxiety, especially in someone presenting with physical symptoms. Mr B had presented with chest tightness and dyspnoea and had been found to have a tachycardia and an elevated blood pressure. All these symptoms can be attributed to anxiety but this should have only been diagnosed after excluding other causes.