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 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. 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 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. 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. Written Assignment: 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? If a serious diagnosis comes to mind based on a patient’s symptoms: •Ask yourself; Have you considered the likelihood of it 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 sufficient understanding of the clinical presentation to offer an opinion on the diagnosis? •What other diagnosis could it be? How might the treatment to date have altered the patient 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? To view the Grading Rubric for this Assignment, please visit the Grading Rubrics section of the Course Resources. Assignment Requirements: Before finalizing your work, you should: •be sure to read the Assignment description carefully (as displayed above); • consult the Grading Rubric (under the Course Resources) to make sure you have included everything necessary; and • Utilize spelling and grammar check to minimize errors. Your writing Assignment should: •follow the conventions of Standard English (correct grammar, punctuation, etc.); • be well ordered, logical, and unified, as well as original and insightful; • display superior content, organization, style, and mechanics; and • use APA 6th Edition format as outlined in the APA Progression Ladd
A Case of Poor Patient Outcome after a Misdiagnosis
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Institution of Affiliation
A Case of Poor Patient Outcome after a Misdiagnosis
A List of Differentials
Poor Patient Outcome after a Misdiagnosis. Medical history and physical examination are what guides a nurse practitioner when coming out with a list of the possible conditions that a client may be having. It is always important to list all the differential diagnoses so that they can be ruled out through proper and comprehensive investigations (Dunphy, Winland-Brown, Porter & Thomas, 2015). It would be better to rule out the possibility of a condition than not to diagnosis it and leading to the bad outcome for the patient. In the case scenario, there are many possibilities that the nurse practitioner would have considered and therefore investigated the patient fully. Having a list of differentials would have made the nurse practitioner to actually investigate the patient fully and hence may not have missed the condition (Green & Thorogood, 2018). Also, this would have led to a timely management of the patient or even referral and the condition would not have led to the death of the patient. These differentials include:
Myocardial Infarction
Despite the patient being relatively young, the patient would have developed the condition which is of sudden onset and pain is constant and radiates to the neck.
Angina Pectoris
Whether it is a stable or not, such a diagnosis should have been thought by the nurse practitioner. The condition is no longer than for the old people only but even the young people are being diagnosed with the condition due to changes in their lifestyle.
Aortic Dissection
This condition is of sudden onset and may even not lead to changes in the blood pressure and other vital signs in the first few hours after its onset. It is therefore important to think of it and hence investigate to rule it out.
Pulmonary Edema
The condition is of sudden onset and is accompanied by severe chest pain and non-productive cough in the first few hours and then cough leads to the production of pink frothy sputum.
Pericardial Effusion
The muffled heart sounds and the chest pain and tenderness could be due to an effusion despite having a normal ECG in the first few hours after onset of the symptoms.
Pericardial Tamponade
The muffled heart sound can be due to the development of the condition which is acute in onset. The pain being worse on inspiration can also support the differential.
Acute Pancreatitis
With the age of the patient, the nurse practitioner should have asked about alcohol intake history and also cigarette smoking. All these are risk factors for acute pancreatitis and the symptoms could also point to the same.
Diagnostics, Labs, and Imaging
Troponin I and T
This is a lab investigation aimed at providing information regarding the integrity of the myocardium. Any heart muscle injury leads to the production of the biomarkers troponin I and T which are specific for the heart (Vetter, 2015). This will inform the nurse practitioner if there is any myocardium injury. This will help to give evidence of a diagnosis of myocardial infarction, pulmonary edema, pericardial tamponade and pericardial effusion.
Full Hemogram
The information from the investigation provides a clue about the blood integrity and if there is any acute blood loss like in a case of aortic dissection. Also, the results will provide information if there is an infection that can lead to pericardial effusion or even pericardial tamponade.
Lipid Profile
This investigation provides information concerning the content of cholesterol quality and content. This would give the nurse practitioner a clue to the cause of a condition like myocardial infarction and pulmonary edema due to heart failure or arrhythmias.
Chest X-ray
The most important basic investigation involving the chest and mediastinum. The investigation can help to provide information concerning the heart size and if there is any fluid accumulation in the pericardium. Cardiomegaly is associated with heart failure which can be caused by myocardial infarction and pulmonary edema (Chen, Hsu, Chang & Lin, 2016). Pulmonary edema can also be shown by the CXR as can be seen by the lung parenchyma changes like Kerley-B lines and prominent blood vessels. Fluid accumulation can also be seen in the pericardium hence support the diagnoses of pericardial effusion and tamponade. Also, aortic dissection is also seen in a CXR.
Echocardiogram
This is an imaging investigation that is directed towards the heart. The investigation provides information about the myocardium integrity and functioning (Vetter, 2015). It provides information if there is any muscle injury that is interfering with cardiac pumping mechanism like muscle contraction in a specific area in case of a myocardial infarction and also in case of a tamponade or even an effusion.
CT Angiogram
It is an important investigation that provides information about the perfusion of the blood vessels in the heart and elsewhere as needed. It will provide the evidence needed to make a diagnosis of a pulmonary edema and also myocardial infarction being caused by an obstruction of the coronary arteries (Green & Thorogood, 2018).
References
Chen, S. L., Hsu, H. Y., Chang, C. F., & Lin, E. C. L. (2016). An exploration of the correlates of nurse practitioners’ clinical decision‐making abilities. Journal of clinical nursing, 25(7-8), 1016-1024.
Dunphy, L. M., Winland-Brown, J., Porter, B., & Thomas, D. (2015). Primary care: Art and science of advanced practice nursing. FA Davis.
Green, J., & Thorogood, N. (2018). Qualitative methods for health research. Sage.
Vetter, M. J. (2015). The influence of clinical decision support on diagnostic accuracy in nurse practitioners. Worldviews on Evidence‐Based Nursing, 12(6), 355-363.