Chest pain and/or breathlessness are 2 of the common and frequent complaints GPs encounter in their daily routine work. Those patients need quick and thorough assessment by GPs relying on clinical skills. Tools of investigations are not readily available in every GP’s surgery; therefore the diagnosis and management could be very difficult.

I carried out an audit in 2004 on a group of patient I have seen for a period of 12 months. Should there be any comments or criticism about this audit please do not hesitate to get in touch with me. My email address is ( barzan@izzat.fsnet.co.uk)

Dr B Izzat MBChB MRCP(UK) MRCGP
GP Partner
Ilford Medical Centre
Ilford Essex IG1 1EE

Audit
April 2004

Chest pain / Breathlessness

To audit the management of patients presented with chest pain and / or shortness of breath (breathlessness). The management of those patients involves their initial clinical assessment, any investigation carried out, whether a referral made to secondary care and analysis of the outcomes.

Criteria

1. There should be no significant and unexpected outcome in all patients.

2. Those presented with chest pain +/- shortness of breath might be at risk of serious or life-threatening conditions (cardiac or respiratory) should be appropriately handled in acute situation. Their management will take into account their age, previous medical history, previous presentation with the same problem and whether they are at high risk.

Standards

Above criteria should be applied to 100% of the patients who are at high risk.

Methods

A computer search was made for all patients seen from January 2003 to December 2003 with a presenting complaint of chest pain( Read code 182) and/ or shortness of breath (Read code 173). The total number was 42 patients. Their details of age, presentation (first time or not), tests carried out, referrals made, on disease register and the outcome were recorded on a spreadsheet. All my consultations are on computer and diagnoses are read coded.

Results

The patients were divided into 2 groups (high and low risk groups).

High risk group

The total number of patients in the high-risk group was 26 and 12 of them presented with shortness of breath (subgroup A), 14 with chest pain (subgroup B).

Subgroup A (shortness of breath group)

4 patients were referred urgently (by 999 ambulance), 3 referred to the outpatient clinic, 5 patients were managed and reassured. Those who referred urgently, each patient was admitted:

1. Pulmonary embolism

2. Asthma and chest infection

3. Liver cirrhosis

4. Heart failure and bronchopneumonia

All those who referred to the outpatient clinic, had a diagnosis of non- acute cardiac/ pulmonary problems.

Those who were managed, reassured and send home had the following outcomes:

2 patients had minor Respiratory Tract Infection
1 patient had asthma
1 patient had ongoing problem of stable AF/CCF
1 had ongoing problem of severe COPD with regular review in the outpatient clinic

Subgroup B (chest pain group)

3 patients were referred urgently (by 999 ambulance), 8 referred to the cardiology clinic, 3 were managed and reassured. Those who referred urgently, 2 of them were admitted with angina and one had non-cardiac diagnosis and discharged from AE. Those who were referred to the clinic had the following outcomes:

6 discharged with non cardiac diagnosis
1 had routine bypass operation after 5 months from the referral
1 the diagnosis still unknown as he is on waiting list for routine angiogram

The last 3 patients had the following outcomes:

2 of them was musculoskeletal
1 was anxiety

Low risk group

16 patients presented with either chest pain or shortness of breath and 6 were under age of 40, 8 were between 40-49 and 2 between 50-59.

2 patients were referred urgently:

1 presented with? DVT? PE, she was admitted, had negative V/Q scan.
1 presented with chest pain and abnormal ECG, was discharged home on the same day.

3 patients were referred to chest pain clinic and all three had a non-cardiac diagnosis.

11 patients were managed and reassured in the surgery and there were no adverse outcome.

Conclusion

1. The audit of all the patients presented to me in 2003 with a complaint of chest pain and/or shortness of breath, did not demonstrate any significant unexpected outcome due to my management of their acute presenting complaint.

2. The audit also demonstrates a significant number of patients in the lower risk category who were referred for further investigation to exclude potentially serious illnesses.

3. The audit was a beneficial exercise in critically appraising my clinical performance in this area and to repeat such exercise in different areas of clinical management in the future.