A previously healthy 35-year-old lawyer presents to a primary care office with a chief complaint of chest pain and a non-productive coug

Topic: Diagnostic Reasoning
Clinical decision making is the process by which we determine who needs what and when. While not exactly arbitrary, this exercise can be quite subjective. Each provider compiles their own data (hence the emphasis on learning to perform an accurate H&P) and then constructs an argument for a particular disease state based on their interpretation of the “facts.” The strength of their case will depend on the way in which they gather and assemble information. There may then be no single, right way of applying diagnostic and therapeutic strategies to a particular case. Medicine involves playing the odds, assessing the relative chance that a patient is/is not suffering from a particular illness. Codifying the way in which providers logically approach problems and deal with this uncertainty is a difficult task. Relying solely on the classic features of a disease may be misleading. That is because the clinical presentation of a disease often varies: the symptoms and signs of many conditions are non-specific initially and may require hours, days, or even months to develop.
Generating a differential diagnosis; that is, developing a list of the possible conditions that might produce a patient’s symptoms and signs, is an important part of clinical reasoning. It enables appropriate testing to rule out possibilities and confirm a final diagnosis.
This case portrays a poor patient outcome after a misdiagnosis.
Case scenario
A previously healthy 35-year-old lawyer presents to a primary care office with a chief complaint of chest pain and a non-productive cough. The pain started suddenly two hours prior to coming to the office while the patient was sitting at his desk. The patient describes the pain as sharp in nature, constantly present but made worse with inspiration and movement, and with radiation to the base of the neck. His blood pressure in the right arm and other vital signs are normal
On physical examination, the only findings of note are chest wall tenderness and a faint cardiac murmur. The ECG in the office is normal. The patient is observed for an hour in the office and assessed. He is diagnosed with viral pleurisy and sent home on non-steroidal analgesics.
The following day the patient collapses at home and cannot be resuscitated by the paramedic service. An autopsy reveals a Type 1 aortic dissection with pericardial tamponade.
Discussion Assignment:
Developing a list of possible conditions that might produce a patient’s symptoms and signs is an important part of clinical reasoning.
As an NP in primary care, what would you have done differently?
Discuss the importance of creating a list of differentials for this patient. How could it have changed this outcome?
If a serious diagnosis comes to mind based on a patient’s symptoms:
Ask yourself: Have you considered the likelihood of a serious diagnosis and whether it needs to be ruled out by testing or referral?
Because many serious disorders are challenging to diagnose, have you considered ruling out the worst-case scenario?
Ask yourself: Do you have a sufficient understanding of the clinical presentation to offer an opinion on the diagnosis?
What other diagnoses could it be? How might the treatment to date have altered the patient’s outcome?
What other diagnostic and laboratory or imaging was needed in order to make a complete differential list? What support tools would you consider using in helping to create a differential diagnosis list?
Are you familiar with the current clinical practice guidelines for the investigation of a suspected condition such as chest pain?
Please support with up-to-date evidence-based standard of care guidelines that are less than 5 years old.
ITS A DISCUSSION POST. ONE PAGE IN LENGTH IS JUST FINE. APA STYLE AND MUST HAVE 3 REFERNECES PLEASE.
ANSWER
As an NP in primary care, I would have done the following differently:
Created a broader differential diagnosis. The patient’s presentation is consistent with a number of possible conditions, including aortic dissection, myocardial infarction, pulmonary embolism, and esophageal rupture. While viral pleurisy is a common cause of chest pain, it is important to consider more serious diagnoses in patients with sudden, severe chest pain.
Ordered additional testing. An ECG is only one part of the evaluation of a patient with chest pain. Other tests that may be helpful include a chest X-ray, blood tests, and cardiac enzymes. In this case, an echocardiogram or CTA of the chest may have been helpful in diagnosing the aortic dissection.
Referred the patient to a cardiologist. Given the patient’s young age, sudden onset of severe chest pain, and atypical presentation, I would have referred him to a cardiologist for further evaluation and management.
Importance of creating a list of differentials for this patient
Creating a list of differentials is important in all patients with chest pain, but it is especially important in patients with atypical presentations, such as this patient. Aortic dissection is a rare but life-threatening condition that can be difficult to diagnose. However, it is important to consider aortic dissection in all patients with sudden, severe chest pain, especially those with risk factors such as hypertension and Marfan syndrome.
Creating a list of differentials can help to ensure that all possible diagnoses are considered and that appropriate testing is ordered. In this case, creating a broader differential diagnosis and ordering additional testing may have led to an earlier diagnosis of aortic dissection and potentially saved the patient’s life.
Other diagnoses that could it be?
Other diagnoses that could have been considered in this patient include:
Myocardial infarction
Pulmonary embolism
Esophageal rupture
Costochondritis
Musculoskeletal pain
Pneumonia
Pericarditis
How might the treatment to date have altered the patient’s outcome?
If aortic dissection had been diagnosed earlier, the patient could have been treated with emergency surgery or endovascular repair. This may have saved his life.
What other diagnostic and laboratory or imaging was needed in order to make a complete differential list?
Other diagnostic and laboratory or imaging tests that may have been helpful in this case include:
Chest X-ray
Blood tests (including cardiac enzymes, troponin, and D-dimer)
Echocardiogram
CTA of the chest
Support tools for creating a differential diagnosis list
There are a number of support tools that can be used to help create a differential diagnosis list. These include:
Computer-assisted decision support systems (CDSS)
Clinical practice guidelines
Textbooks and other reference materials
Consultation with colleagues
Current clinical practice guidelines for the investigation of a suspected condition such as chest pain
The American Heart Association (AHA) recommends the following for the evaluation of patients with chest pain:
Obtain a comprehensive history and physical examination.
Order an ECG.
Consider other tests, such as a chest X-ray, blood tests, and cardiac enzymes, based on the patient’s presentation.
Refer patients with high-risk features, such as recurrent chest pain, atypical features, or significant risk factors, to a cardiologist.
References
American Heart Association. (2021). 2021 AHA/ACC/ASE guideline for the evaluation and diagnosis of chest pain in adults. Circulation, 144(24), e596-e607.
Li, J., & Bhimji, S. (2020). Aortic dissection. In StatPearls [Internet]. StatPearls Publishing.
Tintinalli, J. E., Stapczynski, J. S., Ma, O. J., Yealy, D. L., & Meckler, G. D. (Eds.). (2016). Tintinalli’s emergency medicine: A comprehensive study guide (8th ed.). McGraw-Hill Education.