So today, while on my GP run, I was just organising the store cupboard when the nurse asked me to come see a patient who didn’t have a appointment but had chest pain that was of concern to him and his mother.
Rehearsing SOCRATES for chest pain and the protocol for referral to hospital for heart attack in my head, I went to see the patient. This man was 48 and otherwise well. He presented a history that sounded like reflux/indigestion/heart burn/GORD (GERD for Americans). I arrived at this conclusion because he described a pain radiating up his oesophagus, typically in the morning, with an acid taste in his mouth, and that the pain is relieved on burping. He has had this chest pain for 3-4 years and occasionally had tummy pain.
But this guy was anxious. He was terrified that this was coming from his heart. He had a family history of heart disease on his dad’s side who had passed away from a heart attack at the age of 60. He broke down at the clinic. I reassured him as best as I could that this pain did not sound cardiac and considering his risk factors, it is unlikely to be a heart attack. He had however, not completed any blood tests given to him in the past so technically, I was unaware of his cholesterol status, etc. I told him that the doctor would probably prescribe him omeprazole, and check his H. Pylori status, and order any blood tests to establish his CVD risk for future.
Anyway! He was super anxious and the nurse suggested that we carry out an ecg just incase. To ease his anxiety. She also thought that the history sounded much like reflux. So we hooked him up to an ecg machine and printed an ecg.
And that’s when the problem began. His ecg showed T inversions in lead 1 and what looked like ST depression (I couldn’t actually remember the exact number of squares the wave had to be below to confirm ST depression, but it looked like it to me anyway) in the rhythm strip. There was also evidence of Left ventricular hypertrophy (peaked R waves). Uh oh. Not good. Ran to the GP and showed her the ecg for a second opinion. She said the ecg definitely showed both these things and the patient needed an urgent troponin. She THEN asked me what his history was. I explained that it sounded like a history for reflux and his ecg abnormalities may be an incidental finding.
So the GP took her own history and the patient ended up being referred to hospital. What was interesting, was that the referral stated the findings as “chest pain + ecg changes”. And there didn’t seem to be much detail about the nature of the chest pain. Nothing about the acid taste or the burping relieving the pain.
The patient was discharged later that day. Diagnosis? Chest pain secondary to reflux. Omeprazole charted. Out-patient H. Pylori testing ordered. LVH changes on ecg noted; Echo clear, NAD. No evidence of significant hypertrophy. There was no mention of ST depressions.
I’ve been in hospital. In ED. And I could just see the registrars on acutes rolling their eyes or face-palming at this referral once the history was taken. And the further frustration of the house officer that would be required to type out the discharge summary within 3 hours of the patient arriving in ED.
The funny thing is, this is the second time this has happened while I’ve been on this run. I thought a patient had Bell’s palsy, my GP referred her to hospital for a possible stroke when her only symptom was a droopy lip and a BP of 180/100. Which is fair enough because the high BP means you can’t risk not sending her to hospital. But she was discharged with a diagnosis of Bell’s palsy and antivirals the same day.
What is the discrepancy here? Perhaps because I haven’t known these patients for years as my GP has, I don’t have any preset notions for diagnoses? A colleague presented a case on a discussion board about confirmation bias because the doctor had known the patient for a long time, and hence knows what their most likely diagnosis would be. I wonder if that is what pushed the GP to refer this patient to hospital where the doctors would make a diagnosis based on the patient they see then and there.
But then who’s right? I think one of the peculiar things about medicine as a field is how much variation there can be between doctors and how they practice the same medicine they all learnt. One doctor says stroke, another says oh please just take some prednisone. One doctor says it’s just reflux, another says omg it’s a heart attack! Go to hospital asap!! I mean, who’s practising the best medicine? Does it matter as long as the patient is okay? But then you hear stories of how a patient goes through a bunch of doctors who tell them they’re fine, but then one doctor provides the correct diagnosis that all the others missed. What happens then? Are the other doctors incompetent? I doubt it. Because I’m sure there were other cases that they would have diagnosed brilliantly.
So then, who is the Word?
It’s not like I didn’t know this before, but I’ve just been put in the middle of it I think. And it makes me a little insecure about what type of doctor I will become. Because obviously everyone wants to be that guy at the end of line that picked up on the right diagnosis, because obviously he’s the ‘best’ doctor. But is he? Really? Maybe he just got lucky. Lucky in a sense, anyway.