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From the case files

Each issue the team that bring you Casebook share interesting cases

The heart of the matter

Be wary of being unduly influenced in your medical management by patients who come with a self-diagnosis

Mr G was a 55-year-old art gallery owner, based in a city centre. Over a period of six weeks, he developed a tight, burning sensation in his chest after meals, which cleared when he belched. He took some over-the-counter preparations for heartburn, including antacids. When these failed to alleviate his symptoms, Mr G made an appointment to see Dr V, his GP.

During the consultation with his doctor, Mr G’s blood pressure was recorded as 164/92. Dr V made a note that this was likely to be “white coat hypertension”, and therefore not significant. He advised Mr G to return at his convenience for another BP check-up with the nurse. The medical entry noted the patient as having “heartburn clearing after belching”, with no other details of the nature of the pain, or any exacerbating or relieving factors.

There was no record of whether this was related to exertion. Mr G said himself that he thought it was “probably just some heartburn”. He said that his wife asked him to make the appointment when his self-treatment had failed. Mr G said that he was not really worried about it and thought he’d “just come and get it checked out”.

Dr V diagnosed oesophageal reflux and prescribed a course of ranitidine for two weeks. As Mr G had been treated with some omeprazole four years previously for suspected reflux disease, Dr V recorded that this was most likely a recurrence of the problem, possibly caused by a lifestyle of frequent social engagements.

Over the next three months, Mr G presented to Dr V’s two colleagues in practice, Drs K and B. At each attendance, sparse records were kept, but his blood pressure was recorded as 166/98 and 170/90. Despite this, no further investigations or treatment were ordered. On reviewing the records it was clear the original diagnosis of oesophageal reflux was accepted and not reconsidered by either doctor (or if it was, no record was made in the notes to that effect).

Three months after that initial consultation, at his last practice visit, Mr G reported to Dr V that he had experienced a terrible weekend. There was an opening of an exhibition at the gallery that he had to leave because of extreme dizziness and palpitations. He said it was embarrassing in front of the invited guests and that he had been sweating excessively. Dr V told him it was probably due to the stressful environment and that he had likely experienced a panic attack, prescribing him some propranolol.

One week later, Mr G collapsed and died at home. The postmortem examination was reported as showing left ventricular hypertrophy secondary to hypertension and severe coronary artery disease. Mr G’s widow made a claim against Drs V, K and B.

Expert opinion

Experts concluded that there had been many occasions when the diagnosis could have been made and treatment commenced, and that Mr G’s was an avoidable death. Experts were also critical of the failure to manage Mr G’s blood pressure. The case was settled for a substantial sum.

Learning points

  • Be wary of being unduly influenced in your medical management by patients who come with a self-diagnosis. This can often be wrong and prompt an incorrect treatment pathway. The terminology used by a patient might not be an accurate representation of pathology and can be misleading.
  • Remember that chest pain experienced after a meal, or associated with belching, can also be a sign of angina, rather than a sign of gastro-oesophageal disease.
  • Do not be reluctant to challenge the diagnosis of a colleague, regardless of seniority. Symptoms evolve and change and, with careful history taking, patients can often report different symptoms at subsequent visits, where new diagnostic clues can emerge. Re-examine a patient’s previous history, from the beginning if necessary, if there is a change in symptoms.
  • Remember the importance of actively managing chronic diseases and acting on abnormal signs, eg, elevated blood pressure.
  • Preventative medicine is a large part of primary care and failure to act can result in adverse outcomes. 
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