This case portrays a poor patient outcome after a misdiagnosis.
Poor patient outcome: 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 2 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.
Causes of Poor Patient Outcome
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.
Developing a list of possible conditions that might produce a patient\’s symptoms and signs is an important part of clinical reasoning.
1.As an NP in primary care what would you have done differently?
2.Discuss the importance of creating a list of differentials for this patient. How could it have changed this outcome?