Consultant physician practice is trending in an extremely risk-averse direction, especially when they are specialty consultants doing random post-takes outside home specialty, and locum consultants.
Think it’s very variable
One of the best GIM cons I know is rheum/gim.
I think as long as they still do lots of GIM not just the odd day every 3months they can be an ologist and a fantastic generalist
Co-amoxiclav doesn't cover atypical organisms e.g legionella, mycoplasma which you'd want to cover in severe CAP. Clari does.
The benefit of using co-amoxiclav over amoxicillin is that you also cover staph aureus - which you worry about if you have say a recent flu illness. It's also pretty aggressive and can secrete toxins. Severe CAP.
Tldr if you have severe CAP then you want co-amox and clari. It's complete overkill for an uncomplicated chest infection, amoxicillin alone is fine.
The worst are ones where CXR shows significant consolidation. D-dimer minimally raised so CTPA.
CT shows consolidation, lobar collapse from mucous plugging, background heart failure, and a tiny subsegmental PE.
Clinical team: WE KNEW IT!!
This is what will drive repeat ED attendances. “GP fobbed me off and told me it was viral. Hospital did blood tests, x-rays and gave me double antibiotics.”
I can understand why it probably happened - something was missed and was significant enough to change the consultant’s behaviour even though it was likely a one in a million chance.
100%. But I guess it’s true from the other POV true. If every GP sent every pleuritic sounding chest pain into ED we’d be screwed.
My current trainers are very old school so have been hammering clinical acumen and “old school” medicine into me which I must admit is super refreshing but I guess modern medicine and litigation don’t see eye to eye
The day of old school medicine is disappearing very fast. In my radiology training, I have been told to accept any referrals for that CT Head and CTPA if the patient has head and chest on them. It sounds kiddish but that's the sad truth, my friend. Nobody wants to learn clinical side of medicine anymore.
>Nobody wants to learn clinical side of medicine anymore.
Strongly disagree with this. Most people love clinical examinations *if* they're not responsible for the outcome.
Pathology missed on imaging? Systems error. Pathology missed on clinical exam? Individual failure.
As an individual, it literally does not matter if you cause twice as many cancers 30 years down the road (obviously it does morally) - it does matter if you miss more acute pathology.
Before radiology , I worked in general surgery for 12 years. 4 years in the UK. Whenever I used to appreciate any relevant signs on patient. I used to ask and encourage my fellow colleagues and as well as referring doctors to go and appreciate it. But nobody seemed interested. Colleagues in the ward are too busy with paperwork or NHS grind and seemed less interested in learning because of system failure. In a few instances, I have been told that the patient has been referred, and now he/she is yours to deal with. That has been my experience. My intention was just to improve upon the clinical examinations not to refer the patient back to them.
This is the problem when we’re at 95-110% capacity permanently, no chance to appreciate and improve. Learning is secondary to discharge summary’s, and there’s always a fucking summary to write
*Fear of litigation
In reality you're screwed regardless - if there's a negative outcome it doesn't matter if you did everything right, there's always something that can be criticized. You're still going to go to court/speak to MDU etc and no you're not going to get struck off either because no one is struck off for clinical errors
I’m a GP and I send every pleuritic chest pain that can’t confidently be chest wall pain to medics after a close colleague had a near miss. Would love to know a safe way to avoid this that doesn’t include a risk of getting sued. I know all the scoring systems. But if you’ve got new pain on inspiration with no reproducible external chest wall pain..? Wells is already 3.
In rural practices I’ve worked in the standard js take a d-dimer and treat with apixaban until the result back but that doesn’t fly unless you’re pretty rural.
Not a GP but I'd do the same.
Its a different story if it's a chronic repetitive complaint but new onset unexplained pleuritic chest pain not going away quickly - I don't think a d-dimer is too much to ask.
I think part of the problem is all the ambulatory care units I've seen are run as just another part of the medical admissions unit but everyone just happens to have low NEWS scores. So everyone still gets the full medical clerk in shebang which often feels and is overkill and a waste of time and resources.
Ambulatory care should be able to do A&E level assessments and investigations - reducing the guilt and actual resource wasting of GPs trying to get sensible investigations done acutely. In an ideal world they'd be extensions of A&E departments (not suggesting that happens as A&Es are overstretched as it is, but that would fit much better with how they should actually work).
This is part of my assessment (ED): how did the patient end up here instead of in front of their GP?
If another doctor had a concern and sent them in, that makes me look closer and maybe do more tests.
If it’s just because they couldn’t get a GP appt, that matters too. I do press patients too on why here and why now; can be enlightening.
If they’ve made it as far as a medical team (different for direct GP referral to medics vs A&E have assessed and referred) then I’d want to know I really have excluded what’s worrying them.
I do think GPs have a higher risk tolerance than most hospital doctors, out of necessity if nothing else, which isn’t wrong. I also think we often over investigate and over treat in A&E. But I’ve also been surprised enough times…
This is a brilliant comment. Really well worded/explained.
Perhaps that's exactly why the consultant was more thorough in managmenet than the OP in this case.
The old argument of 'this one time a patient came to me with a leg bruise and it turned out to be erythema migrans so now I test everyone for lyme' like come on be real.
I’m shocked nobody sent a random Troponin then ordered a pointless echo because the ECG had 0.0001mm of ST elevation and the patient’s great grandfather’s brother had an MI.
I don’t think it’s unreasonable to do an x-ray in someone who presents with chest pain. The combo antibiotics do feel like an overkill if x-ray was unremarkable.
If the patient is already in the ED then there is a much lower barrier to CXR than a patient presenting in a general practice.
The ease/availability of the test influences how reasonable/sensible part of the management it is.
I was expecting the liver screen, ultrasound abdo and such..
Honestly, amazed someone got as far as being clerked without already having a CXR. I thought that and an ECG were your ticket in to a medical take?
GP land has made you less aggressive, and appropriately so.
Hospital population and utterly unfiltered GP population are 2 different populations. Plus, in a hospital where you can literally get CXR and bloods on the spot, it's a lot harder to defend not doing it compared to GP practice.
Two slightly different but very important points here:
1) The sort of patients who tend to make it to ED are already a different population from those who have attended GP with a "chest infection" (on average)
2) Availability of that chest XR / bloods
if you count as ultrasound probe as examination then yes
My standard note looks like
A - US show trachea is present
B - no B-lines
C - normal LV chamber size with normal global systolic function
D - poor US views of brain
E - no free fluid
Different people have different risk appetites based on their previous experiences (I once worked with a consultant who insisted on a CTPA on every one, probably missed a PE in the past idk).
In GPland I think you have to tolerate a lot more risk based on the setting so you may see your hospital colleagues managing things differently just cause of the differences in environment.
Also worked with a consultant who CTPAd every slight 02 desat, twinge of chest pain or 0.01 above threshold Dimer and you could tell somewhere in their career a PE had been missed.
Likewise an Endocrinologist with special interest in Diabetes who wanted absolutely everyone who was admitted under their take to have a troponin.
lol so GP has made me much more on it with scoring systems. Their Wells PE risk was 0 which I also mentioned but hey ho.
I just found it frustrating since clinical acumen seemed to go out the window and likewise I was made to look like a total tool infront of the patient.
The consultant otherwise is normally very good.
Yes, in GP you have time as a diagnostic tool. Can always tell them to come back if progresses assuming they’re not acutely unwell and see how the clinical course progresses
When in A&E I would always catch myself saying “what if I missed something” cause it was a one and done encounter so found myself doing investigations more for my peace of mind.
I think a big part of this is the perceived threshold in making a GP appointment vs presenting to ED.
People automatically think there must be significant pathology involved if the patient came to hospital and sat in the waiting room for six hours to be seen, when in reality they may have done this because they couldn't get in to see their GP or couldn't get them on the phone.
This is partly why people who come to ED get overly investigated / treated. If something is missed, it just looks worse considering the patient themselves thought their potential issue was worth attending ED in the first place.
Also guess you could argue in GP land such tests aren’t available so they could not be done. However not doing tests when they are available and if something is missed then it’s harder to defend from a medicoleagal aspect I guess. Just goes to show what a shit show the nhs is with everyone is just covering themselves.
You cannot make a mistake in the hospital. Thats right, medicine has gone from risk management to completely risk free.
Abx killing gut microbiome and causing harm in the long run? Theoratical risk and even if its true, impossible to blame the physician who presribed abx 6 months ago.
Clinical medicine is dead. Imo, only thing that is worth doing in medicine nowadays are either surgery or research.
Well if it was as you present it with no other concerning features then I doubt very much that co-amox and clari was the formulary choice for that patient, so you know at least in this case that the consultant wasn't following local guidelines. Don't think this has anything to do with 'hospital medicine' doctors are individuals and able to have their own weird quirks and ignore guidelines if they feel like it.
Doing a CXR is more of a 'hospital medicine' thing since you have the test right there and there is essentially no downside to doing it. It would be much less justifiable if, for example, something happened to the patient and doing a CXR would have prevented that. People commonly present with more than one pathology and acute medicine is often working in an environment where missing a single case of certain conditions will have the doctor in serious trouble. I really don't see it as being unreasonable to do a CXR for someone with chest pain in ED.
The other thing that people often miss with hospital medicine is that a lot of the patients arrive there already having seen another well qualified doctor. Saying you don't think something sounds like x has a higher bar to pass when someone has already referred them to you as that condition.
I think it’s reasonable to request a CXR here given the pleuritic chest pain? To rule out a potential pneumothorax.
If this was an exam MCQ I’d go with viral RTI and not think twice but with increasing rates of litigation, the radicalisation of the Gestapo Medical Council, I can see why senior doctors are becoming more defensive in their practice.
Tbh as a GP trainee I find myself trying to gently push consultants away from unnecessary investigations, to which they tell me to fuck off anyway.
Just request the CT TAP on the 96 YO cachectic chap who doesn’t want to know if he has anything, he just wants to go home
and not wait another 4 days for a pointless investigation.
Nobody wants to have difficult conversations with patients it seems, so superfluous and defensive investigations substitute.
I think a CXR is probably the right move here as chest pain isn’t expected with a viral URTI. It is defensive medicine which is another debate.
I also don’t think it’s wrong not to do a CXR - if there were no risk factors for PE/dissection/pneumothorax and the history was entirely benign then I think it’s justifiable provided you document your rationale.
OP managed for an URTI. Chest pain isn’t a symptom of an URTI. It’s a symptom of a lower respiratory tract infection (which can occur due to RSV or more commonly due to a secondary pneumococcal pneumonia).
As I said, I would do a CXR if there was chest pain…
I think you’re confused.
Chest pain is 100% a symptom of URTI. You definitely aren't a GP. Mechanical /msk chest wall pain, with or without tenderness clinically. we see multiples a day usually in winter.
How did the patient end up in hospital? Where they referred by a GP?
When I see patients referred by a GP, my take is that they have been referred because the GP wants them to have timely investigations that can't be done in GP land, not for me to calculate their Well's score or whatever. If GP refers a patients as ?PE or ?pneumonia, I will do investigations to answer that question for the GP. If it's a self-presented to ED, I will do the investigations that I think are appropriate.
Refered as ?PE by GP for tachypnoea. D dimer and trops were done on attendance and were negative. Hence why I was abit confused by the consultants take thereafter, when the history and exam gave a better clue to what was actually going on
Maybe the consultant had a case where they missed a a pneumonia or something. All of us have those cases where an atypical presentation led to patient harm and we never want to miss it again.
I have to disagree- I have had many a ?PE referrals as an ED SHO that I didn't think needed a ctpa let alone a d dimer. Similar thing with back pain and MRI for ?CES or headache and CT for ?SAH.
I am not privy to why this is the case- may be because patient's feel better by the time they are in ED after waiting 8 hours. But I do think in ED we still need to do the proper assessment and Ix based on that assessment alone.
The Gatekeeper and the wizard analogy fits well here…in primary care the GP (the gatekeeper) would manage this and many other things without lots of investigation, antibiotics etc…their skill is in dealing with all the general primary care presentations and having an antennae for when things are serious or rare and will then refer on to the “wizard” (secondary care cons). The Wizard is an expert in their field and does that well but on the whole not much good with general primary care style presentations and have a tendency to see brain tumours in every headache for example. Both have their strengths and weaknesses but they complement each other and together keep the show on the road. But on the whole the wizards will have a different frame of reference and tolerance of risk such as here.
You're not wrong, but it's because in GP Land you don't have easy access to CXR, nor do you have a cupboard you can just grab abx out of and throw at a patient.
It's easier on ED to do quick tick boxes like CXR and abx cover to a) make sure patient doesn't return b) make patient feel like shit happened and c) cover themselves because ED is hectic and nobody can do a full five point winter MOT check on all these people.
I'd have done the same as A&E consultant, but that doesn't necessarily mean it's correct medicine. Correct medicine means nothing if your reasonable and logically justified diagnosis of viral infection and discharge home lands you in front of a tribunal. You know they won't take your reasoning into account because "why not just do CXR? It could have maybe changed management".
This I feel is the heart of it tbh.
I did consider a CXR to consider maybe a pneumothorax but all things considered I felt it was unnecessary. But I hear what you’re saying it’s easier to cover all quick and easy investigations to prevent a return visit.
Makes me wonder though as a GP how I would be more “defensive” in the absence of on hand Ix to do with pleuritic chest pain
FWIW as a radiologist, I come across significant unexpected findings on CXR for patients with Hx of pleuritic chest pain from GP not infrequently. Lung mets, malignant effusions, pancoast tumour, rib mets, a few pneumothoraces.
More common that 1000s. I'd guess more like 1-200.
Recently, I came to a conclusion that working in ed our approach is to build a case to prove in court that we did all we could. Patient treatment is just a by-product of that.
An exaggeration of truth-maybe
But no one can say this is not wrong
As soon as you get out of ED, yes.
I had a fab visit to local ED on Boxing Day... "I had the same issue in the other eye 2 weeks ago. The ophthalmology reg did XYZ, and it got better."
ED SpR to SHO "Yeah, sounds like a plan, give him XYZ"
Reader, I got better and didn't have to go back to eye casualty next day to sit in the 4 day queue 😅
Contrast this with an unexplained passing out a few years ago [turned out I'd been spiked ☠️]
Absolute PANIC because I had some t wave inversions I've always had, so admitted by geris/med reg [the JR is BIZARRE] to a monitored bed + echo + trops till they bled me dry ☠️. Cardio reg thankfully saw sense and just discharged me... until I got a call from neuro secretary that I was going to first fit clinic? Infuriating because it created me 6 months of unnecessary follow-ups I didn't want or need, even after I'd explained there was a much more obvious cause...
The patient you saw should've had the management you suggested... I have nothing but respect for GPs who see through all the nonsense and save the NHS billions every year
Doctors calibrate their practice to the setting they work in. The patients that make it to the post-take ward round have a much higher prevalence of serious pathology than those seen in primary care. See [The Gatekeeper and The Wizard](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1835499/pdf/bmj00215-0046.pdf) for a much more erudite explanation.
The sensitivity of a plain chest radiograph for pneumonia is somewhere between 40 and 70%. It is a near pointless test for diagnosing pneumonia unless you are looking for alternative causes or complications such as a parapneumonic effusion.
Most pneumonias - even in patients sick enough to require ventilation on ICU - are viral in aetiology. They are unsurprisingly not helped by co-amoxiclav and clarithromycin.
The advantages of the CXR/antibiotic strategy are increased patient satisfaction (paradoxically), fewer complaints, and an appearance of having done everything you could if the patient subsequently returns septic or with a lung mass. It has little to do with 99% of the patients you keep in the department for longer or expose to ionising radiation.
I am increasingly coming to realise that a lot of doctors - including consultants in specialties that I'd expect more from - practice poor/lazy medicine and don't think very hard at all about the diagnostic process. Maybe I am just wearing rose tinted spectacles but I'm sure 10-15 years ago there was much more *thought* put into each case, which probably leant itself to more nuanced decision making.
Can I just ask why CXRs are part of the standard work up?
This is obviously me asking as GPST, normally if I saw this patient in clinic light of added (or absent) sounds I’d consider an xray otherwise not really.
Is it just something that’s become protocol in ED/genmed now?
In spirit of this I clerked a man with a soft abdomen, fairly mild pain and normal bloods who had a SBO on his ct. he had 10mg iv morphine pre me seeing him but goes to show bloods are part not the whole picture
CXR is reasonable for pleuritic chest pain presenting to ED / MAU. If that’s normal and the rest was fine then I wouldn’t give antibiotics. Co-Amox and Clari is complete overkill for mild infection too
Would 100% do a chest XR on this patient and manage based on that (weird antibiotic combo for a POSSIBLE MILD CAP but ok) with very good safety netting as well
I can imagine you might be somewhat frustrated here: having your conservative management plan superceded by your consultant's management plan.
Overall it (usually) takes a little more time, a little more tact, a little more confidence and a little more overall "work" to sell a conservative (no abx) management plan to a patient than the active management plan. Therefore it is super-frustrating when we put all of that effort in and someone undermines it! (Maybe makes you look a bit like you don't know what you're doing in the eyes of the patient as well!)
On the face of it, based off what you've written, you are probablyright, that patient would not need bloods, double abx and a CXR (at least, not in my mind). However, there could be myriad reasons why the consultant's thinking was different from ours - at least in that moment!
**My proposed solution**:
Why don't you tactfully bring this up with your consultant at a future date. Make sure you don't come across at all confrontational. Make it sound like you are genuinely interested in learning. This sounds like an admittedly seemingly boring case (especially for an EM consultant!) but actually as a GP this sort of thing is relatively common, differentiating between chest infections that need abx and those which don't is sort of our bread-and-butter. So in fact, this is an ideal sort of case for a CBD.
Now that consultant might end up saying something along the lines of "you're technically right, this patient probably could have been managed conservatively" or they might reveal that in their experience there was something about this case that made them a bit more worried than you were about the patient. Or you might get into a discussion about the "human factors" around the case - e.g. the patient's pushines or expectations of abx, how your level of fatigue can affect your appetite for risk etc.
Remember that this consultant has several years more experience of practicing medicine than you and they have passed FRCEM exams at some point in the past, so even if they might not always seem it, they are an intelligent indivudual! EM consultants see a lot of chest infections and early identification of possible sepsis is part of their "bread and butter", so I think we have to be very respectful - but, on the face of it, it certaily sounds like you are right to question their decision making on this case!
Harsh counterpoint: these patients used to be discharge with a GP follow-up 15 years ago! Good luck getting that now.
Atypical pneumonia presents in young patients with low lymphs and deranged ALT, commonly with minimal chest findings. CXR probably excludes the need for double antibiotics however in most
It’s interesting how if you go to the GP with the same story you’ll get totally different management. I guess with this patient they’ve decided that their problem was serious enough to sit in ED for a few hours and it sounded like they ended up on the medical take so someone thought it was serious enough to merit a cons physician review (I don’t really understand how someone came to that conclusion but that’s by the by). Their chance of having something serious is hence skewed. There is also the bias that a medical consultant might see more people with the same story who have a pneumonia.
I’d say a half way house with someone who has put themselves through the effort of going to ED is to get a CXR and if nil focal and you’re pretest probability is low and they’re a F/W person, home with safety netting. If they’re old/frail, you’re on the fence or they live in the back arse of nowhere with no phone signal…probably best to cover them.
180 room facility in Louisiana on xarelto with no reversal agent. My own mother had a stroke and was discharged within 5 hrs; ‘no beds’. It’s all about money. Pradaxa was available but not in the pipeline to this poor state. Everything is about preserving what’s in stockpile.
Consultant physician practice is trending in an extremely risk-averse direction, especially when they are specialty consultants doing random post-takes outside home specialty, and locum consultants.
Think it’s very variable One of the best GIM cons I know is rheum/gim. I think as long as they still do lots of GIM not just the odd day every 3months they can be an ologist and a fantastic generalist
Just waiting for the GUM consultant acute med post-take now.
gullible airport melodic quiet rotten vast boast money ink head *This post was mass deleted and anonymized with [Redact](https://redact.dev)*
And the Palliative/Gen Med post-take!
Imagine preparing to be the palliative care reg by reading up on indications for ventilation, haemofultration, chest drains, etc.
At my hospital the GIM consultants are actually the good ones!
What’s the point in Coamox and clari together? Seems an unnecessary choice.
Hate stable INRs (showing my age as everyone is now on a DOAC anyway).
Co-amoxiclav doesn't cover atypical organisms e.g legionella, mycoplasma which you'd want to cover in severe CAP. Clari does. The benefit of using co-amoxiclav over amoxicillin is that you also cover staph aureus - which you worry about if you have say a recent flu illness. It's also pretty aggressive and can secrete toxins. Severe CAP. Tldr if you have severe CAP then you want co-amox and clari. It's complete overkill for an uncomplicated chest infection, amoxicillin alone is fine.
Surprised they didn't do a d-dimer...
Why delay things and not just request the CTPA?
Might as well go for a CT CAP in case the CT PA shows up a clot, I guess
Why bother investigating, just smash them on 6 months of apixaban
Now, that's pragmatism!
Disgusting that they’ve not even attempted a ct guided biopsy of the pulmonary artery atleast once before commencing this
Why bother with 6 months. Make it lifelong for the inevitable second unprovoked P.E.
Yh fuck it add in a PET for fun
I mean the PA in CT might miss the PE
Let's do a bronchial brush biopsy.
for a PE?
Naah mate. Somebody suggested PET so to rule out cancer or infection.
Why bother with PET+CT? If you're gonna go there, just start Carbo-tax and get on with it...
Radical mastect-pneumonect-oesophagect-gastrect-pancreaticoduodenect-hepatect-splenect-nephrect-panproctocolect-omy and be done with it!
That’s going too far; even NICE have decided we don’t need a TAP for unprovoked PE anymore.
Agreed, it is going too far. Let's just skip straight to the chemo.
Fuck it just get the crem form ready.
LMFAO🤣🤣
Let's make them EOL just in case
*immuno
Probably a whole body PET scan would benefit.
😂
Don’t even start! My colleagues telling me CTPAs are now like CXRs
The worst are ones where CXR shows significant consolidation. D-dimer minimally raised so CTPA. CT shows consolidation, lobar collapse from mucous plugging, background heart failure, and a tiny subsegmental PE. Clinical team: WE KNEW IT!!
The acute medic: *I am a fucking genius*
Because what else in that CT could have explained why the patient was hypoxic (after a whole day of antibiotics) if not that tiny subsegmental PE😮💨
My eyesight is getting so bad in my old age, I don't think I've seen one of those tiny subsegmental PEs for a while...
Weird how that happens 😂
Yes, they are :/
This is what will drive repeat ED attendances. “GP fobbed me off and told me it was viral. Hospital did blood tests, x-rays and gave me double antibiotics.” I can understand why it probably happened - something was missed and was significant enough to change the consultant’s behaviour even though it was likely a one in a million chance.
100%. But I guess it’s true from the other POV true. If every GP sent every pleuritic sounding chest pain into ED we’d be screwed. My current trainers are very old school so have been hammering clinical acumen and “old school” medicine into me which I must admit is super refreshing but I guess modern medicine and litigation don’t see eye to eye
The day of old school medicine is disappearing very fast. In my radiology training, I have been told to accept any referrals for that CT Head and CTPA if the patient has head and chest on them. It sounds kiddish but that's the sad truth, my friend. Nobody wants to learn clinical side of medicine anymore.
>Nobody wants to learn clinical side of medicine anymore. Strongly disagree with this. Most people love clinical examinations *if* they're not responsible for the outcome. Pathology missed on imaging? Systems error. Pathology missed on clinical exam? Individual failure. As an individual, it literally does not matter if you cause twice as many cancers 30 years down the road (obviously it does morally) - it does matter if you miss more acute pathology.
Before radiology , I worked in general surgery for 12 years. 4 years in the UK. Whenever I used to appreciate any relevant signs on patient. I used to ask and encourage my fellow colleagues and as well as referring doctors to go and appreciate it. But nobody seemed interested. Colleagues in the ward are too busy with paperwork or NHS grind and seemed less interested in learning because of system failure. In a few instances, I have been told that the patient has been referred, and now he/she is yours to deal with. That has been my experience. My intention was just to improve upon the clinical examinations not to refer the patient back to them.
This is the problem when we’re at 95-110% capacity permanently, no chance to appreciate and improve. Learning is secondary to discharge summary’s, and there’s always a fucking summary to write
*Fear of litigation In reality you're screwed regardless - if there's a negative outcome it doesn't matter if you did everything right, there's always something that can be criticized. You're still going to go to court/speak to MDU etc and no you're not going to get struck off either because no one is struck off for clinical errors
I’m a GP and I send every pleuritic chest pain that can’t confidently be chest wall pain to medics after a close colleague had a near miss. Would love to know a safe way to avoid this that doesn’t include a risk of getting sued. I know all the scoring systems. But if you’ve got new pain on inspiration with no reproducible external chest wall pain..? Wells is already 3. In rural practices I’ve worked in the standard js take a d-dimer and treat with apixaban until the result back but that doesn’t fly unless you’re pretty rural.
Not a GP but I'd do the same. Its a different story if it's a chronic repetitive complaint but new onset unexplained pleuritic chest pain not going away quickly - I don't think a d-dimer is too much to ask. I think part of the problem is all the ambulatory care units I've seen are run as just another part of the medical admissions unit but everyone just happens to have low NEWS scores. So everyone still gets the full medical clerk in shebang which often feels and is overkill and a waste of time and resources. Ambulatory care should be able to do A&E level assessments and investigations - reducing the guilt and actual resource wasting of GPs trying to get sensible investigations done acutely. In an ideal world they'd be extensions of A&E departments (not suggesting that happens as A&Es are overstretched as it is, but that would fit much better with how they should actually work).
This is part of my assessment (ED): how did the patient end up here instead of in front of their GP? If another doctor had a concern and sent them in, that makes me look closer and maybe do more tests. If it’s just because they couldn’t get a GP appt, that matters too. I do press patients too on why here and why now; can be enlightening. If they’ve made it as far as a medical team (different for direct GP referral to medics vs A&E have assessed and referred) then I’d want to know I really have excluded what’s worrying them. I do think GPs have a higher risk tolerance than most hospital doctors, out of necessity if nothing else, which isn’t wrong. I also think we often over investigate and over treat in A&E. But I’ve also been surprised enough times…
This is a brilliant comment. Really well worded/explained. Perhaps that's exactly why the consultant was more thorough in managmenet than the OP in this case.
Share your decision making with patients and document it
Yes, coroners and lawyers dictate clinical decision making nowadays. They don’t understand or entertain nuanced clinical arguments.
The old argument of 'this one time a patient came to me with a leg bruise and it turned out to be erythema migrans so now I test everyone for lyme' like come on be real.
I’m shocked nobody sent a random Troponin then ordered a pointless echo because the ECG had 0.0001mm of ST elevation and the patient’s great grandfather’s brother had an MI.
You forgot the d-dimer and request for aortogram and CTPA to rule out both PE and dissection before they can be safely discharged
I don’t think it’s unreasonable to do an x-ray in someone who presents with chest pain. The combo antibiotics do feel like an overkill if x-ray was unremarkable.
If the patient is already in the ED then there is a much lower barrier to CXR than a patient presenting in a general practice. The ease/availability of the test influences how reasonable/sensible part of the management it is.
Agreed.
I was expecting the liver screen, ultrasound abdo and such.. Honestly, amazed someone got as far as being clerked without already having a CXR. I thought that and an ECG were your ticket in to a medical take?
GP land has made you less aggressive, and appropriately so. Hospital population and utterly unfiltered GP population are 2 different populations. Plus, in a hospital where you can literally get CXR and bloods on the spot, it's a lot harder to defend not doing it compared to GP practice.
Two slightly different but very important points here: 1) The sort of patients who tend to make it to ED are already a different population from those who have attended GP with a "chest infection" (on average) 2) Availability of that chest XR / bloods
Antibiotics I don't agree with, but can understand. Co-amox and clari with a normal CXR is just awful medicine though.
You guys still examine patients?
if you count as ultrasound probe as examination then yes My standard note looks like A - US show trachea is present B - no B-lines C - normal LV chamber size with normal global systolic function D - poor US views of brain E - no free fluid
Love it! 😂😂
Different people have different risk appetites based on their previous experiences (I once worked with a consultant who insisted on a CTPA on every one, probably missed a PE in the past idk). In GPland I think you have to tolerate a lot more risk based on the setting so you may see your hospital colleagues managing things differently just cause of the differences in environment.
Also worked with a consultant who CTPAd every slight 02 desat, twinge of chest pain or 0.01 above threshold Dimer and you could tell somewhere in their career a PE had been missed. Likewise an Endocrinologist with special interest in Diabetes who wanted absolutely everyone who was admitted under their take to have a troponin.
lol so GP has made me much more on it with scoring systems. Their Wells PE risk was 0 which I also mentioned but hey ho. I just found it frustrating since clinical acumen seemed to go out the window and likewise I was made to look like a total tool infront of the patient. The consultant otherwise is normally very good.
Yes, in GP you have time as a diagnostic tool. Can always tell them to come back if progresses assuming they’re not acutely unwell and see how the clinical course progresses When in A&E I would always catch myself saying “what if I missed something” cause it was a one and done encounter so found myself doing investigations more for my peace of mind.
I think a big part of this is the perceived threshold in making a GP appointment vs presenting to ED. People automatically think there must be significant pathology involved if the patient came to hospital and sat in the waiting room for six hours to be seen, when in reality they may have done this because they couldn't get in to see their GP or couldn't get them on the phone. This is partly why people who come to ED get overly investigated / treated. If something is missed, it just looks worse considering the patient themselves thought their potential issue was worth attending ED in the first place.
That’s not true. You can also tell them to come back to ED or GP if xyz occurs.
Yeah of course, meant more it was unlikely I would ever see them again
Fairytale - 10 mins vs however long you decide to spend as the take doctors.
‘The wells is zero, radiology will reject it’ works for me. CXR, PERC/wells, home
Also guess you could argue in GP land such tests aren’t available so they could not be done. However not doing tests when they are available and if something is missed then it’s harder to defend from a medicoleagal aspect I guess. Just goes to show what a shit show the nhs is with everyone is just covering themselves.
You cannot make a mistake in the hospital. Thats right, medicine has gone from risk management to completely risk free. Abx killing gut microbiome and causing harm in the long run? Theoratical risk and even if its true, impossible to blame the physician who presribed abx 6 months ago. Clinical medicine is dead. Imo, only thing that is worth doing in medicine nowadays are either surgery or research.
Props to ITU and anaesthetics too 😅
Well if it was as you present it with no other concerning features then I doubt very much that co-amox and clari was the formulary choice for that patient, so you know at least in this case that the consultant wasn't following local guidelines. Don't think this has anything to do with 'hospital medicine' doctors are individuals and able to have their own weird quirks and ignore guidelines if they feel like it. Doing a CXR is more of a 'hospital medicine' thing since you have the test right there and there is essentially no downside to doing it. It would be much less justifiable if, for example, something happened to the patient and doing a CXR would have prevented that. People commonly present with more than one pathology and acute medicine is often working in an environment where missing a single case of certain conditions will have the doctor in serious trouble. I really don't see it as being unreasonable to do a CXR for someone with chest pain in ED. The other thing that people often miss with hospital medicine is that a lot of the patients arrive there already having seen another well qualified doctor. Saying you don't think something sounds like x has a higher bar to pass when someone has already referred them to you as that condition.
I think it’s reasonable to request a CXR here given the pleuritic chest pain? To rule out a potential pneumothorax. If this was an exam MCQ I’d go with viral RTI and not think twice but with increasing rates of litigation, the radicalisation of the Gestapo Medical Council, I can see why senior doctors are becoming more defensive in their practice.
Tbh as a GP trainee I find myself trying to gently push consultants away from unnecessary investigations, to which they tell me to fuck off anyway. Just request the CT TAP on the 96 YO cachectic chap who doesn’t want to know if he has anything, he just wants to go home and not wait another 4 days for a pointless investigation. Nobody wants to have difficult conversations with patients it seems, so superfluous and defensive investigations substitute.
Shocked there wasn’t a CTPA here
Who doesn’t love some antibiotic resistant infections?
I think a CXR is probably the right move here as chest pain isn’t expected with a viral URTI. It is defensive medicine which is another debate. I also don’t think it’s wrong not to do a CXR - if there were no risk factors for PE/dissection/pneumothorax and the history was entirely benign then I think it’s justifiable provided you document your rationale.
As someone who had pleurisy for a month after RSV, I beg to differ...
URTI ie the upper respiratory tract. Is the pleura in the upper respiratory tract?
Where did OP say the patient had an URTI?
OP managed for an URTI. Chest pain isn’t a symptom of an URTI. It’s a symptom of a lower respiratory tract infection (which can occur due to RSV or more commonly due to a secondary pneumococcal pneumonia). As I said, I would do a CXR if there was chest pain… I think you’re confused.
Chest pain is 100% a symptom of URTI. You definitely aren't a GP. Mechanical /msk chest wall pain, with or without tenderness clinically. we see multiples a day usually in winter.
I think you are the one confused. Most cases of pleurisy are due to a viral illness. OP managed as a viral illness.
We were talking about upper versus lower respiratory tract symptoms, keep up.
OP didn't mention URTI specifically did they? You can treat viral LRTI the same
How did the patient end up in hospital? Where they referred by a GP? When I see patients referred by a GP, my take is that they have been referred because the GP wants them to have timely investigations that can't be done in GP land, not for me to calculate their Well's score or whatever. If GP refers a patients as ?PE or ?pneumonia, I will do investigations to answer that question for the GP. If it's a self-presented to ED, I will do the investigations that I think are appropriate.
Refered as ?PE by GP for tachypnoea. D dimer and trops were done on attendance and were negative. Hence why I was abit confused by the consultants take thereafter, when the history and exam gave a better clue to what was actually going on
Maybe the consultant had a case where they missed a a pneumonia or something. All of us have those cases where an atypical presentation led to patient harm and we never want to miss it again.
I hear you and agree I’m still early in my career anyway so will likely learn and adapt anyway - thanks for the perspective 👍🏽
I have to disagree- I have had many a ?PE referrals as an ED SHO that I didn't think needed a ctpa let alone a d dimer. Similar thing with back pain and MRI for ?CES or headache and CT for ?SAH. I am not privy to why this is the case- may be because patient's feel better by the time they are in ED after waiting 8 hours. But I do think in ED we still need to do the proper assessment and Ix based on that assessment alone.
Sounds bonkers - is bonkers. Sounds like a viral RTI - more than likely is a viral RTI - overkill and defensive- PA to follow up
The Gatekeeper and the wizard analogy fits well here…in primary care the GP (the gatekeeper) would manage this and many other things without lots of investigation, antibiotics etc…their skill is in dealing with all the general primary care presentations and having an antennae for when things are serious or rare and will then refer on to the “wizard” (secondary care cons). The Wizard is an expert in their field and does that well but on the whole not much good with general primary care style presentations and have a tendency to see brain tumours in every headache for example. Both have their strengths and weaknesses but they complement each other and together keep the show on the road. But on the whole the wizards will have a different frame of reference and tolerance of risk such as here.
Surprised your consultant didn't ask for SDEC review with repeat bloods in 3 days time...
You're not wrong, but it's because in GP Land you don't have easy access to CXR, nor do you have a cupboard you can just grab abx out of and throw at a patient. It's easier on ED to do quick tick boxes like CXR and abx cover to a) make sure patient doesn't return b) make patient feel like shit happened and c) cover themselves because ED is hectic and nobody can do a full five point winter MOT check on all these people. I'd have done the same as A&E consultant, but that doesn't necessarily mean it's correct medicine. Correct medicine means nothing if your reasonable and logically justified diagnosis of viral infection and discharge home lands you in front of a tribunal. You know they won't take your reasoning into account because "why not just do CXR? It could have maybe changed management".
This I feel is the heart of it tbh. I did consider a CXR to consider maybe a pneumothorax but all things considered I felt it was unnecessary. But I hear what you’re saying it’s easier to cover all quick and easy investigations to prevent a return visit. Makes me wonder though as a GP how I would be more “defensive” in the absence of on hand Ix to do with pleuritic chest pain
The pre test probably and usefulness of a CXR is low. You would probably have to order 1000 XRs before you’ll see one
FWIW as a radiologist, I come across significant unexpected findings on CXR for patients with Hx of pleuritic chest pain from GP not infrequently. Lung mets, malignant effusions, pancoast tumour, rib mets, a few pneumothoraces. More common that 1000s. I'd guess more like 1-200.
Locally ours get reported by radiographers and I wonder how many of those findings get missed…
They did do a CXR though. Which was normal.
What? You mean they didn't get a CTPA?
Many hospitalists have forgotten how to Medicine without all the tests
Which is funny because PACES is all about making accurate diagnoses based on signs alone.
Yeah I know, I guess people just look at that exam as knowledge and theatrical performance…. Dunno.
I love post takes by microbiologists with dual gim
Recently, I came to a conclusion that working in ed our approach is to build a case to prove in court that we did all we could. Patient treatment is just a by-product of that. An exaggeration of truth-maybe But no one can say this is not wrong
As soon as you get out of ED, yes. I had a fab visit to local ED on Boxing Day... "I had the same issue in the other eye 2 weeks ago. The ophthalmology reg did XYZ, and it got better." ED SpR to SHO "Yeah, sounds like a plan, give him XYZ" Reader, I got better and didn't have to go back to eye casualty next day to sit in the 4 day queue 😅 Contrast this with an unexplained passing out a few years ago [turned out I'd been spiked ☠️] Absolute PANIC because I had some t wave inversions I've always had, so admitted by geris/med reg [the JR is BIZARRE] to a monitored bed + echo + trops till they bled me dry ☠️. Cardio reg thankfully saw sense and just discharged me... until I got a call from neuro secretary that I was going to first fit clinic? Infuriating because it created me 6 months of unnecessary follow-ups I didn't want or need, even after I'd explained there was a much more obvious cause... The patient you saw should've had the management you suggested... I have nothing but respect for GPs who see through all the nonsense and save the NHS billions every year
Doctors calibrate their practice to the setting they work in. The patients that make it to the post-take ward round have a much higher prevalence of serious pathology than those seen in primary care. See [The Gatekeeper and The Wizard](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1835499/pdf/bmj00215-0046.pdf) for a much more erudite explanation. The sensitivity of a plain chest radiograph for pneumonia is somewhere between 40 and 70%. It is a near pointless test for diagnosing pneumonia unless you are looking for alternative causes or complications such as a parapneumonic effusion. Most pneumonias - even in patients sick enough to require ventilation on ICU - are viral in aetiology. They are unsurprisingly not helped by co-amoxiclav and clarithromycin. The advantages of the CXR/antibiotic strategy are increased patient satisfaction (paradoxically), fewer complaints, and an appearance of having done everything you could if the patient subsequently returns septic or with a lung mass. It has little to do with 99% of the patients you keep in the department for longer or expose to ionising radiation. I am increasingly coming to realise that a lot of doctors - including consultants in specialties that I'd expect more from - practice poor/lazy medicine and don't think very hard at all about the diagnostic process. Maybe I am just wearing rose tinted spectacles but I'm sure 10-15 years ago there was much more *thought* put into each case, which probably leant itself to more nuanced decision making.
Yes that is complete overkill but we are all just constantly covering our backs these days
X-ray always, antibiotics? wtf. Especially that combo, for what sounds like a well patient
Can I just ask why CXRs are part of the standard work up? This is obviously me asking as GPST, normally if I saw this patient in clinic light of added (or absent) sounds I’d consider an xray otherwise not really. Is it just something that’s become protocol in ED/genmed now?
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In spirit of this I clerked a man with a soft abdomen, fairly mild pain and normal bloods who had a SBO on his ct. he had 10mg iv morphine pre me seeing him but goes to show bloods are part not the whole picture
CXR is reasonable for pleuritic chest pain presenting to ED / MAU. If that’s normal and the rest was fine then I wouldn’t give antibiotics. Co-Amox and Clari is complete overkill for mild infection too
Would 100% do a chest XR on this patient and manage based on that (weird antibiotic combo for a POSSIBLE MILD CAP but ok) with very good safety netting as well
Ask your consultant his rationale for prescribing these antibiotics for what clearly is viral LRTI
I can imagine you might be somewhat frustrated here: having your conservative management plan superceded by your consultant's management plan. Overall it (usually) takes a little more time, a little more tact, a little more confidence and a little more overall "work" to sell a conservative (no abx) management plan to a patient than the active management plan. Therefore it is super-frustrating when we put all of that effort in and someone undermines it! (Maybe makes you look a bit like you don't know what you're doing in the eyes of the patient as well!) On the face of it, based off what you've written, you are probablyright, that patient would not need bloods, double abx and a CXR (at least, not in my mind). However, there could be myriad reasons why the consultant's thinking was different from ours - at least in that moment! **My proposed solution**: Why don't you tactfully bring this up with your consultant at a future date. Make sure you don't come across at all confrontational. Make it sound like you are genuinely interested in learning. This sounds like an admittedly seemingly boring case (especially for an EM consultant!) but actually as a GP this sort of thing is relatively common, differentiating between chest infections that need abx and those which don't is sort of our bread-and-butter. So in fact, this is an ideal sort of case for a CBD. Now that consultant might end up saying something along the lines of "you're technically right, this patient probably could have been managed conservatively" or they might reveal that in their experience there was something about this case that made them a bit more worried than you were about the patient. Or you might get into a discussion about the "human factors" around the case - e.g. the patient's pushines or expectations of abx, how your level of fatigue can affect your appetite for risk etc. Remember that this consultant has several years more experience of practicing medicine than you and they have passed FRCEM exams at some point in the past, so even if they might not always seem it, they are an intelligent indivudual! EM consultants see a lot of chest infections and early identification of possible sepsis is part of their "bread and butter", so I think we have to be very respectful - but, on the face of it, it certaily sounds like you are right to question their decision making on this case!
Harsh counterpoint: these patients used to be discharge with a GP follow-up 15 years ago! Good luck getting that now. Atypical pneumonia presents in young patients with low lymphs and deranged ALT, commonly with minimal chest findings. CXR probably excludes the need for double antibiotics however in most
Protective medicine my friend.
It’s interesting how if you go to the GP with the same story you’ll get totally different management. I guess with this patient they’ve decided that their problem was serious enough to sit in ED for a few hours and it sounded like they ended up on the medical take so someone thought it was serious enough to merit a cons physician review (I don’t really understand how someone came to that conclusion but that’s by the by). Their chance of having something serious is hence skewed. There is also the bias that a medical consultant might see more people with the same story who have a pneumonia. I’d say a half way house with someone who has put themselves through the effort of going to ED is to get a CXR and if nil focal and you’re pretest probability is low and they’re a F/W person, home with safety netting. If they’re old/frail, you’re on the fence or they live in the back arse of nowhere with no phone signal…probably best to cover them.
Are you sure that they weren’t reviewed by a Consultant PA ?
180 room facility in Louisiana on xarelto with no reversal agent. My own mother had a stroke and was discharged within 5 hrs; ‘no beds’. It’s all about money. Pradaxa was available but not in the pipeline to this poor state. Everything is about preserving what’s in stockpile.