Healthcare professionals deal with increased pressure from all the stakeholders to improve the efficiency of services. Chest pain assessment is one of the spheres that is associated with numerous trade-offs. On the one hand, discharging a patient with a possibly life-threatening condition is unacceptable since it can lead to missing a high-risk cardiac diagnosis. On the other hand, all patients cannot be admitted for evaluation of chest discomfort due to the rising cost of care and dedication to reducing hospitalization. The present paper offers a case study and discusses the importance of the differential diagnosis of patients presented with pleuritic chest pain.
A lawyer is presented in primary care with sharp, constantly present chest pain and unproductive cough. The pain worsens on inspiration and radiates to the neck, and there are no detected abnormalities except faint cardiac murmur and chest wall tenderness. The patient is diagnosed with viral pleurisy and prescribed non-steroidal analgesics. The following day the patient dies from Type 1 aortic dissection with pericardial tamponade.
As a nurse practitioner (NP) in primary care, I would have approached the patient differently in a number of ways. On the one hand, according to Januzzi, and McCarthy (2018), cardiovascular causes of chest pain may be present in 20% of patients, and only 5.5% of these patients have a life-threatening condition that needs immediate treatment. On the other hand, if a serious diagnosis comes to mind based on a patient’s symptoms, it is vital to evaluate its likelihood. In the present case, the healthcare practitioner failed to make additional tests and referrals to rule out the immediately dangerous diagnoses. The professional seems to have ruled out the worst-case scenario but was unable to acquire a sufficient understanding of the clinical presentation.
First, I would have created a list of differential diagnoses to understand which conditions are to be ruled out. In order to make a complete list of differentials, I would have used clinical guidelines and recent research. According to Reamy, Williams, and Odom (2017), the list includes pulmonary embolism, myocardial infarction, pericarditis, aortic dissection, pneumonia, and pneumothorax. The complete list of serious conditions helps to identify the worst-case scenario and act accordingly. In the present situation, the worst-case scenario is myocardial infarction, which was ruled out by the electrocardiogram (ECG). However, the risk of pericarditis and aortic dissection was left unattended, which led to adverse outcomes. The situation could have been avoided if the care provider had used a recent evidence-based guideline of chest pain assessment.
Second, I would have gathered a complete family history and used electrocardiography, troponin assays, blood test, and chest radiography for preliminary testing. According to the guideline provided by Januzzi and McCarthy (2018), the test results would have provided me with enough information to identify the risk level of the current condition and consider admitting the patients. If the matter remained unclear, I would use additional tests such as d-dimer assays, ventilation-perfusion scans, or computed tomography angiography (Reamy et al., 2017). However, these tests would have been scheduled in the hospital.
Importance of Differential Diagnosis
The importance of differential diagnosis in chest pain assessment is hard to overstate. According to Kaiser (2016), the term is understood as “distinguishing a condition as the potential cause of a patient’s illness via process of elimination” (para. 14). When clinicians consider a diagnosis, they use the knowledge in pathophysiology and apply it to the objective and subjective data. In the present case, creating a list of differentials could have changed the outcome. Although the process does not guarantee diagnostic certainty, the method is useful for narrowing down the list of possible conditions and start managing the most dangerous ones.
In the present case, the list of possible conditions would have provided a clinician with valuable information that would have changed the outcome. Differential diagnosis would have made it clear that ECG and checking blood pressure in only one arm does provide sufficient evidence to rule out aortic dissection. A simple x-ray test or measuring blood pressure on both arms could have given additional information for making the right clinical decision. The patient would have been given beta-blockers and nitroprusside to prevent the condition from worsening, and surgery would have been scheduled. Therefore, the differential diagnosis would have helped to avoid the death of the patient by explicitly showing the incompleteness of the clinical picture.
The present case shows that increased pressure on clinicians to reduce admission rates is positively correlated with the number of poor patient outcomes. Even though care providers are to make every effort to reduce the cost of treatment, they should consider efficient strategies for avoiding diagnostic mistakes. In this situation, the elaboration of the list of possible conditions is of increased importance. Evidence-based guidelines are to be consulted while assessing patients and making a differential diagnosis. In the present case, the clinician failed to elaborate the list of differentials, and the fact prevented him or her from recognizing what information was needed to rule out life-threatening conditions.
Januzzi, J. L., & McCarthy, C. P. (2018). Evaluating chest pain in the emergency department. Journal of the American College of Cardiology, 71(6), 617–619. Web.
Kaiser, C. (2016). Differential diagnoses are important for patient outcomes. Patient Care 3(41). Web.
Reamy, B., Williams, P., & Odom, M. (2017). Pleuritic chest pain: Sorting through the differential diagnosis. Am Fam Physician, 96(5), 306-312.