Case 29 Indigestion in a stressed executive
Malcolm was a 46-year-old senior banking executive in the City who had a BMI of 37 and smoked. When he consulted Dr Mathers it was usually in order to request a private referral to a named specialist whom a colleague or friend had recommended. He always appeared rushed and tended to dominate consultations. On this occasion he saw Dr Mathers and asked for a referral to a back specialist whose details he supplied. Dr Mathers noticed that the last recorded blood pressure was 5 years earlier and a letter from an occupational health assessment had noted a blood pressure of 190/110 mmHg 2 years earlier. Dr Mathers checked his blood pressure and noted it was 170/104 mmHg. He asked Malcolm to have his blood pressure checked twice further by the nurse and have blood tests and an ECG. However, Malcolm did not attend for another 7 months.
On the next occasion Malcolm consulted Dr Mathers he was not sleeping, sweating a lot and had been getting burning retrosternal chest discomfort at night. He sometimes felt breathless. Malcolm was extremely stressed because his department had lost a great deal of money and he was being held responsible. Dr Mathers noted that he had consulted the Out of Hours service two weeks earlier with dysuria, was noted to have microscopic haematuria and had been treated with an antibiotic. Dr Mathers noted that chest examination was normal but his blood pressure was 184/112 mmHg.
What would you do now?
Dr Mathers arranged for Malcolm to have an ECG with the nurse. This was normal. He prescribed amlodipine 5 mg daily and omeprazole 20 mg daily, arranged for Malcolm to have some routine blood tests and referred him for a private cardiology opinion.
What would be your differential diagnosis have been and how would you discriminate between them?
Unfortunately, 4 days later Malcolm was found dead in bed by his wife. His wife said that he had been complaining of chest pains and breathlessness for several days. At post mortem he had widespread coronary atheroma, no myocardial infarction but a grossly hypertrophied and dilated heart with extensive myocardial fibrosis. There was also pulmonary oedema and congestion.
His wife brought an action against Dr Mathers and the practice for failing to adequately monitor or treat Malcolm’s blood pressure and for failing to recognize symptoms of myocardial ischaemia.
Do you think his claim will succeed?
Expert comment
The assessment of chest pain continues to cause problems for general practitioners and cases of sudden cardiac death, missed heart failure and myocardial infarction continue to be common causes of litigation. One difficulty is that chest pain is very common. A fulltime general practitioner can expect to see a new case every one to two weeks. Musculoskeletal chest pain and gastro oesophageal reflux (GORD) are very common causes – but stable angina, unstable angina and myocardial infarction are also not rare. A particular diagnostic problem is when there is a history of chest pain but the patient has not got chest pain at the time of the assessment.
In this case, as is often the case, there was a problem for Dr Mathers’ defence because the characteristics of the chest pain were not well documented. In particular, there were no details about how long the chest pains had been occurring, how frequently they occurred, how long the episodes lasted and whether they were related to exertion or not. It was also not clear if the episodes of breathlessness were associated in time with the chest pains or not.
An additional problem was that the purpose of the ECG was not clear from Dr Mather’s clinical note. If it was to exclude angina or an acute coronary syndrome then it was clearly unsafe.
In March 2010 the UK’s National Institute of Clinical Excellence (NICE) produced guidance on the Assessment of Chest Pain of Recent Onset (CG 95).
The guidance points out that it is generally safe and reasonable to exclude a diagnosis of stable angina if the characteristics of the pain are non-anginal. Typical anginal pain has three characteristics. It is:
