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Troublesome chest pain

01 September 2007

Mr F was a 46-year-old accountant who lived with his wife and two children. He booked an appointment with his GP, Dr P, in an emergency surgery, the morning after experiencing some chest pain. He had been running for a train on the way back from a meeting.

He saw Dr P, who took a brief history. It was Mr F’s first such episode, and he did not appear concerned. He had only come because his wife had encouraged him to and felt it was “probably nothing”. Following the consultation, Dr P got distracted and did not complete his notes. He did not record the details of the chest pain, including its nature, any associated features, or risk factors. There was no evidence that he had asked any of the relevant questions, given appropriate advice or discussed a management plan including “safety-netting”. His only note stated “chest pain – mild, first episode”.

Four weeks later Mr F returned to the surgery and saw Dr P again. From the notes made by Dr P it seems that the patient complained of chest pain but again there were no details to suggest a thorough history had been taken. Mr F said that he had recently stopped smoking.

Mr F carried on with his daily life and returned to the GP three weeks later. He had experienced the chest pain on a number of occasions and felt it was becoming more frequent. This time he saw a different doctor in the practice, Dr R, who spent ten minutes with Mr F, found out the details of the pain, examined him, and sent him to the practice nurse for an ECG.

His note from the consultation read: “Complaining of intermittent chest pain over the past two months, central, associated with shortness of breath, no radiation, severity 5/10, each episode lasts approximately five minutes. Pain brought on by exertion and on one occasion after food. Risk factors: ex smoker, father had CABG [Coronary Artery Bypass Grafting].” On examination Dr R found that Mr F had a blood pressure of 150/100; otherwise, there were no significant findings. Dr R reviewed the ECG, which showed normal sinus rhythm with no ischaemic changes. Dr R was reassured by the normal ECG and the fact that Mr F was not currently complaining of chest pain. His documented impression read “chest pain ?angina”. The management plan included Bisoprolol 5mg once daily to treat hypertension, aspirin 75mg once daily and GTN spray as required. Mr F was also advised to book another appointment if the pain worsened or, if it was severe and he was worried, to go to A&E. Dr R did not refer to cardiology services at this point or for an exercise ECG.

Two weeks later Mr F came to the GP surgery and saw Dr P. He complained of chest pain the night before, following a big meal. The pain had been worse than the previous episodes. He had tried the GTN spray once and it had not eased it. The pain eventually subsided after approximately 20 minutes. Mr F said that he felt quite lethargic, possibly because of broken sleep the previous night. He had suffered a few further episodes of chest pain lasting approximately five minutes each.

There was no radiation, but he did state he was very sweaty during the period when the pain was severe. Mr F explained the chest pains were becoming more frequent and he had noticed them at rest and after big meals. On this history, Dr P’s impression was “gastritis”. He stopped the aspirin and prescribed a proton pump inhibitor.

Mr F went home and was found collapsed by his wife when she returned from work later on that day. She called 999 and started CPR but, despite continued resuscitation in A&E, Mr F died.

The postmortem examination showed that Mr F died of a large inferior myocardial infarction.

Expert opinion

The GP expert who reviewed this case was critical of two main aspects in the care Mr F had received from Dr P and Dr R. The first of these was the poor record keeping by Dr P. The second was that neither doctor referred Mr F to cardiology, either when symptoms didn’t settle or, indeed, when they got worse. The case was settled for a moderate sum.

Learning points

  • It is essential to make clear notes, giving the salient points of the history, examination, an impression and management plan. Without this documentation the content of any consultation is lost. Whether or not the GP made a complete assessment, inadequate notes give a poor impression of the doctor’s capability and competence.
  • It is important to follow local guidelines for the investigation and treatment of patients with ischaemic heart disease. This should include taking account of the relevant risk factors.