Many of us have seen patients presenting with vague symptoms that do not fit in with the pathologies that we can recognise quickly. It is always tempting to label the condition quickly or refer the patient on to someone else. If you are a little patient and spend that extra minute or two with the patient you will be directed in the right direction and the patient will be ever so grateful for your attention to detail. The following case illustrates my point.

Mr “W” a 55 year old diabetic who was a warehouse employee started getting pain across his shoulders when lifting boxes or walking. He saw Dr A who noted a 9 month history of pain in the upper back and around his chest on certain movements. She also noted that the pain came after walking and relieved by rest. On examination she found tenderness over the mid dorsal spine. She concluded that the pain was musculoskeletal in nature and advised him anti inflammatory medication and a weeks rest from work.

Two weeks later patient returned to the surgery as there was no improvement. This time he was referred for physiotherapy. As again there was no improvement after 4 months the patient saw another doctor at the same surgery. This time the doctor diagnosed thoracic root pain. An x-ray of the spine appeared normal and the patient was referred to the pain clinic. The referral letter stated that the pain was worse on the left side and brought on by physical activity and stress.

The pain clinic consultant recorded a 2 year history of pain between the shoulder blades and noted that pain was produced by pressure just lateral to D 6 spine. He diagnosed myofascial pain and injected the trigger points.

Three months later as Mr W was struggling with the pain he saw his family doctor again who referred him to an orthopaedic surgeon. The ortho surgeon thought he had some ligamentous laxity and offered him sclerosant injections. After a year as the pain worsened he was referred back to the orthopaedic team. This time the consultant who examined him could not find any neurological or orthopaedic cause for the pain and discharged him as having psychosomatic symptoms.

Six months later as the patient was struggling to work he requested another appointment with his GP. This time he was seen by a locum doctor. She recorded a history of chest and back pain of several years duration made worse by lifting and exercise. The pain occurred almost every day now with a tight feeling. She also recorded that he was a diabetic, smoked heavily and his mother had died of myocardial infarction at the age of 58. She referred him to the rapid access chest pain clinic.

Angina pectoris was diagnosed and ECG indicated a previous inferior myocardial infarction. Mr.W was found to have severe 3 vessel disease. He underwent a coronary artery bypass grafting and had an uneventful recovery. He continued to have some back pain.

He sued the first two doctors for delay in diagnosis and for not recognising his symptoms as serious.

Experts who went through the case concluded that the patient had two different causes for his pain – coronary artery occlusion and chronic musculoskeletal pain. It was thought that the angina had presented in an atypical manner which had lead the doctors to miss the diagnosis. However it was felt that when symptoms persisted with a history of pain occurring with stress and exertion they should have suspected angina. The doctors should have assessed cardiovascular risk factors sooner. The opinion of a cardiology consultant was that a diabetic patient was likely to have atypical symptoms with angina and depending on which part of the heart was deprived of blood supply, the pain can sometimes be situated more posteriorly.
Based on the experts opinion the case was settled for a high sum.

Learning Points here:
• Angina can present with atypical symptoms particularly in women, older patients and in diabetics. You must always rule out angina when someone presents with back or chest pain on exertion or stress.

Nice guidelines in UK on angina:
• Constricting discomort at the front of the chest, the neck, shoulders or arm.
• Pain precipitated by physical exertion.
• Relieved by rest or glyceryl trinitrate within 5 minutes

Typical angina patients will have all 3. In atypical angina at least 2 of the above will be present.

My take on this:
The most important lesson from this case is – Do not be led by the opinion and findings of a previous examiner. When a patient is referred to you, start with a fresh history. Do not be led by the history on the referral letter. Examine the patient with no bias. The patient may present with two entirely different conditions as it happened here. The worst thing that you can do is to label someone’s symptoms as psychosomatic when you are unable to find a cause (from your speciality point of view). The orthopaedic surgeon in this case should have said that he was not able to find an orthopaedic cause for the pain and not offer a diagnosis of which he knew nothing about.

This was a medico legal case presented in UK and reported by MPS in their Case Reports