Patient Assessment and Diagnostic Risk: Reconsidering Persistent Chest Pain

Description

A patient with recurrent chest pain was evaluated across multiple encounters before ultimately presenting to the ED with an acute myocardial infarction. This case explores how persistent symptoms and incomplete assessment can contribute to delayed diagnosis.

Key Lesson(s)

• Persistent or worsening symptoms should prompt reassessment of the working diagnosis.
• Follow-up encounters, patient messages, and repeat visits are opportunities to identify evolving clinical problems.
• Diagnostic uncertainty should be communicated clearly and specific follow up instructions shared with the patient.

Clinical sequence

In October, the 46-year-old patient with a history of obesity was seen by physician #1 for possible reflux symptoms with heartburn episodes in the prior few weeks that were worse when laying down. An ECG was done and interpreted as normal. Lab work noted slightly elevated cholesterol. They were diagnosed with unspecified chest pain and GERD. The patient was prescribed medications for GERD.

In January, the patient was seen for their annual physical by their doctor, physician #2. The patient’s family history was not updated or reviewed, which included a family history of cardiac disease. The physician noted the patient was not consistent with follow-up for labs, referrals or medications. The patient complained of mild chest pain after eating and said they had started their GERD medications two weeks earlier. Dietary counseling and exercise were discussed; however, the patient did not feel they were overweight and stated they exercised 3 times/week. The patient’s symptoms were attributed to GERD, and they were instructed to continue their GERD medications without further testing.

In April, the patient returned to the office with continued complaints of chest pain and stressful days at work. Physician #2’s documentation notes the pain occurs after eating. The note did not include a description of the pain. Another ECG was done and interpreted as normal. A referral was made to GI for indigestion.

In June, the patient went to the ED with complaints of chest pain. They were diagnosed with an MI and underwent a stenting procedure.

Allegation

The plaintiff alleged a missed diagnosis of cardiac disease caused a delay in treatment. They suffered a heart attack, had prolonged hospitalization, missed work and experienced long term side effects related to the acute myocardial infarction.

Disposition

The case was settled against physician #2, physician #1 was dismissed. 

Analysis

Avoid premature closure and anchoring bias.

• Every visit is an opportunity to re-evaluate. Persistent or worsening symptoms should prompt reassessment of the working diagnosis

Diagnostic uncertainty and next steps should be communicated to the patient.

• Clear communication helps patients recognize worsening symptoms and when to seek additional evaluation

Specify clinical rationale behind decision making

• Reduces loss of information that may impact ongoing care and medical decision making

Reflection Questions

• At what point in this patient’s course would you have reconsidered the original assessment, and why?
• When seeing a patient who has previously been evaluated by another clinician, what strategies do you use to independently review the working diagnosis rather than relying on the prior assessment?
• After reviewing the case, is there one thing you will change in practice?

References

• Tools to Improve Diagnostic Safety
• Diagnostic Errors UC Davis PSNet Editorial Team | June 15, 2024

This is a fictitious case that illustrates commonly encountered issues and is for educational purposes only. Any resemblance to real persons, living or dead, is purely coincidental.