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Mr W was a 55-year-old diabetic who worked in a warehouse. He began to get pain across his shoulders when he was lifting boxes and walking home. He saw his GP, Dr I, who noted a nine-month history of pain in his upper back and around his chest on certain movements. She documented that the pain came on after walking and was relieved by rest. Her examination found tenderness in the midthoracic spine. Dr I considered that the pain was musculoskeletal in nature and advised anti-inflammatory medication and one week off work.

Two weeks later Mr W returned to his GP because the pain had not improved. This time Dr I referred him to physiotherapy. Mr W did not find the physiotherapy helpful and four months later saw another GP, Dr J, who diagnosed thoracic root pain and prescribed dothiepin. He also requested an x-ray of the patient’s spine, which was normal, and referred him to the pain clinic. The referral letter described pain worse on the left side that was brought on by physical activity and stress.

At the pain clinic, a consultant documented a two-year history of pain between the shoulder blades. The examination notes stated that direct pressure to a point lateral to the thoracic spine at T6 could produce most of the pain. Myofascial pain was diagnosed and injections at trigger points were administered.

Three months later Mr W was still struggling with intermittent pain in his upper back. He went back to see Dr J, who referred him to orthopaedics. His referral letter described pain in the upper thoracic region with radiation to the left side, aggravated by strenuous activity and stress. Again, it was recorded that the pain was reproduced by pressure to the left thoracic soft tissues.

Two months later Mr W was assessed by an orthopaedic surgeon who diagnosed ligamentous laxity and offered him sclerosant injections.

Mr W took on a less physically demanding role and the pain came on less often. After one year, however, his discomfort increased and his GP referred him back to the orthopaedic team.

A consultant orthopaedic surgeon found nothing of concern in his musculoskeletal or neurological examination. X-rays were repeated and reported as normal. It was thought that his symptoms were psychosomatic and he was discharged.

Six months later, Mr W was struggling to work at all. He rang his GP surgery and was given an appointment with a locum GP, Dr R. Her notes detailed a several-year history of chest M and back pain on lifting and exercise that had worsened recently. Pain was recorded as occurring every day and being “tight” in character. It was also noted that he was diabetic, smoked heavily and that his mother had died of a myocardial infarction at the age of 58. Dr R referred him to the rapid access chest pain clinic.

Angina pectoris was diagnosed and an ECG indicated a previous inferior myocardial infarction. Mr W was found to have severe three-vessel disease and underwent coronary artery bypass grafting, from which he made an uncomplicated recovery. He was followed up in the cardiology clinic and continued to be troubled by some back pain.

Mr W brought a claim against GPs Dr I and Dr J for the delay in diagnosis of his angina. 

Expert opinion

Medical Protection sought the advice of an expert GP, Dr U. Dr U pointed out that Mr W appeared to have two chest pain syndromes. That is, coronary artery disease, which caused angina, and chronic musculoskeletal pain, which caused back and chest pain (as evidenced by continuing musculoskeletal pain even after coronary surgery). She thought that his angina had presented in a very atypical manner with features that had reasonably dissuaded the GPs and specialists from making the diagnosis. She supported the GPs’ early management but believed that angina should have been considered when Mr W failed to respond to treatment. Dr U commented that pain brought on by stress and exertion should have raised suspicions of angina. She also felt that the GPs should have assessed cardiovascular risk factors sooner.

An opinion from a consultant cardiologist, Dr M, was also sought. Dr M explained that diabetic patients are more likely to have atypical presentations of angina and that, depending on which part of the heart is deprived of blood supply, the pain can sometimes be situated more posteriorly. He commented that if Mr W had been diagnosed earlier he would have commenced aspirin, statin, and beta-blocker therapy and been advised to stop smoking. This would have reduced his risk of myocardial infarction. Dr M believed that if this had been prevented Mr W’s life expectancy could have been improved.

Based on the expert opinion, the case was deemed indefensible and was settled for a high amount

Learning points

• Pain that is precipitated by exertion should always raise suspicion of angina pectoris. NICE1 defines stable angina symptoms as being:
  • constricting discomfort in the front of the chest, in the neck, shoulders, jaw, or arms;
    precipitated by physical exertion; and
    relieved by rest or glyceryl trinitrate within about five minutes.
  • People with typical angina have all three of the above features. People with atypical angina have two of the above features.
  • Angina can present in uncharacteristic ways. There can be vague chest discomfort or pain not located in the chest (including the neck, back, arms, epigastrium or shoulder), shortness of breath, fatigue, nausea, or indigestion-like symptoms. Atypical presentations are more frequently seen in women, older patients and diabetics.2
• Multiple conditions can run alongside each other and we must try to untangle them by careful questioning and listening. Stepping back and looking at the bigger picture can help if a patient’s symptoms are persistent.
• Confirmation bias can lead to medical error. The interpretation of information acquired later in a medical work-up might be biased by earlier judgments. When we take medical histories it can be tempting to ask questions that seek information confirming earlier judgements, thus failing to discover key facts. We also can stop asking questions because we have reached an early conclusion. The BMJ published an article about the cognitive processes involved in decision making and the pitfalls that can lead to medical error.

References

1. NICE, Chest Pain of Recent Onset: Assessment and Diagnosis of Recent Onset Chest Pain or Discomfort of Suspected Cardiac Origin (2010)
2. Abrams J, Chronic Stable Angina, N Engl J Med 352:2524–33 (2005)
3. Klein JG, Five Pitfalls in Decisions about Diagnosis and Prescribing, BMJ 330(7494): 781–3 (2005)