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Short Notes on Acute Chest Pain 2017 - Dr Mark Burgin

21/09/17. Dr. Mark Burgin BM BCh (oxon) MRCGP considers the elements that should be included in a primer for clinical negligence cases involving Acute Chest Pain.

Acute Chest Pain can be muscular skeletal (MSK) like, sharp pain easily localised and worse with movement or visceral type, burning pressure pain that radiates to the back, jaw and arm.

Basic nursing observations (blood pressure, capillary refill, oxygen saturation, pulse, respiratory rate and temperature) should be performed in every case to detect serious causes.

GPs accept varying levels of risk so that a GP who has performed a proper assessment will rarely be found to be in breach.

There are number of risk calculators for different diseases but no overall Acute Chest Pain risk calculator meaning that failing to calculate risk is not in breach but cardiac risk factors must be assessed in every case. (1)

Primary Cardiac prevention

There is a risk calculator that GPs should use in every health check to determine the risk for cardiovascular disease as a percentage chance over the next 10 years. (2)

This allows the GP to determine what preventative steps should be taken for an individual patient based upon the risk thresholds for various treatments.

Those presenting with acute chest pain due cardiovascular disease will have a case against any general practitioner who failed to provide preventative care.

The date of knowledge is often an issue in these cases as the breaches may have occurred up to a decade previously although it can be argued that the claimant was not aware of the breach until they developed acute chest pain.

Pulmonary embolism

A commonly missed cause of chest pain is Pulmonary embolism (PE) where a clot travels from the deep veins and blocks the arteries to the lungs but is diagnosed as muscular skeletal (MSK).

There can be chest pain in the area of the embolus which is sharp on breathing and is associated with a cough, like a chest infection so the doctors arrange a chest x-ray.

The chest x-ray is usually clear because the blood flow is reduced by the clot and the patient can be discharged with a nonspecific MSK diagnosis of muscle strain or costochondritis.

Examination of the legs often shows an abnormality and the D Dimer blood test shows a raised level confirming that a clot is present, the PE is then confirmed on a CT angiogram.

The Modified Well’s score checks if the patient has had a previous clot, been immobile, coughed up blood or has cancer and failure to ask these questions when making a MSK diagnosis would be in breach. (3)

Peptic ulcer disease

Although peptic ulcers are in the abdomen the pain can often be in the chest and back with the abdomen recorded ‘soft non tender’, the chest pain can even be identical to angina and is called ‘heartburn’.

Chest pain from acid will also be relieved by GTN as the drug reduces soft tissue spasm in the gastrointestinal system and the pain from acid can be made worse with physical activity especially with bending.

The chest pain then can be diagnosed as typical angina and the patient is started on the normal drugs which includes aspirin (4) - shortly after the patient is admitted with gastrointestinal haemorrhage or perforation.

It is often difficult to demonstrate that the GP did not follow the correct procedure or should have considered peptic ulcers or even that the bleeding or perforation would not have occurred in any case.

Almost all patients with peptic ulcer disease have a history of symptoms that have been missed and many have a contraindication to aspirin in the medical records.

Conclusions

Chest pain has the potential for serious outcomes including death and is considered to be a ‘red flag’, a symptom that is concerning until it is made safe.

Records of a consultation for chest pain should be longer and more detailed than for a less serious symptom and should specifically exclude common life threatening diagnoses.

GPs should review the patient’s records for contra-indications prior to prescribing or advising drugs with known toxic effects in line with GMC advice.

The primer should include research of the number of cases clinical negligence lawyers see involving the management of acute chest pain as the problem may be underestimated.

Doctor Mark Burgin, BM BCh (oxon) MRCGP is on the General Practitioner Specialist Register.
Dr. Burgin can be contacted This email address is being protected from spambots. You need JavaScript enabled to view it. and 0845 331 3304 website drmarkburgin.co.uk

  1. NICE 2010 Chest pain of recent onset: assessment and diagnosis nice.org.uk/guidance/cg95

  2. QRISK®2-2016 risk calculator: https://qrisk.org

  3. Philip S. Wells 2001 Excluding Pulmonary Embolism at the Bedside without Diagnostic Imaging: Management of Patients with Suspected Pulmonary Embolism Presenting to the Emergency Department by Using a Simple Clinical Model and d-dimer Ann Intern Med. 2001;135:98-107

  4. NICE 2011 Stable angina: management nice.org.uk/guidance/cg126.

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