Chest Pain assessment Case Scenario
The initial nursing assessment, the first step of the nursing process, is critical in determining the well being of the patient and the subsequent care. The presenting signs and symptoms of patients can be misleading and can cause the wrong diagnosis which can greatly affect the prognosis of the patient’s condition. Using differential diagnosis is important for nurses and other healthcare professionals to rule out other possibilities during the confirmation of the actual diagnosis. Additionally, nurses should use critical thinking and decision making skills to ensure patients leave the healthcare facility safer than they came. Chest pain is a commonly encountered symptom in outpatient clinics and emergency departments resulting from multiple conditions that can be minor or life-threatening. The initial assessment and the use of diagnostic tools is important to guide the management of the condition. This discussion analyzes a case of chest pain that was misdiagnosed, how clinical reasoning by advanced nurse practitioners can change future outcomes, and how differential diagnosis can help in improving patient outcomes.
The case for discussion is about a 35-year old patient who presented to a primary care office with complaints of chest pain and non-productive cough. Upon history taking, the pain had started two hours before the visit and was described as sharp, constantly present, and aggravated with inspiration and movement. Further assessment revealed chest wall tenderness and faint cardiac murmur. The provider proceeded to do an ECG which revealed normal results alongside other vitals. Based on the assessment and examination findings, the patient was observed for an hour and discharged home on non-steroidal analgesics. The following day the patient collapsed and died and upon performing an autopsy, the results revealed type 1 aortic dissection with pericardial tamponade. From the case scenario, it is evident that the patient had a medical condition that was not identified during the initial visit. The primary healthcare provider performed an initial assessment but failed to include differential diagnoses that could have guided treatment of the patient and perhaps affect the outcome.
What Could Have Been Different
Medical errors are the third leading cause of death in the United States with 1% of hospital admissions resulting to adverse events due to misdiagnosis. It is estimated that about 12 million people suffer a diagnostic error each year in a primary care setting, 33% of which result in permanent damage or death (Geoffrey et al., 2017). The above case scenario represents an adverse outcome of misdiagnosis for the patient and I believe many things could have been done differently to save the life of the patient. First, the physical examination and investigations from the primary care provider were insufficient to lead to the diagnosis of viral pleurisy. It is observed that the blood pressure readings were taken from the right-hand side only. I believe the results could have been optimal if readings from both sides were taken as recommended. Secondly, patients with chest problems and suspected heart conditions should be checked for pulse both in the upper and lower extremities. Pulse differences are common in about 20% of patients with an intimal flap or compression hematoma (Patel & Arora, 2017). Approaching the patient from this angle could have altered the initial diagnosis.
Clinical reasoning and understanding of different presentations of diseases are among the core strengths of advanced nurse practitioners (Geoffrey et al., 2017). The patient presented with a faint cardiac murmur which was indicative of a heart condition. Perhaps, the primary care provider should have thought of aortic regurgitation which is present in about half of the patients that present with diastolic murmurs. These findings are indicative of proximal aortic dissection and the fact that the murmur was faint could have led to the diagnosis of the condition. An ECG is an important diagnostic tool for patients with heart conditions such as myocardial infarction, aortic distention, and acute coronary syndrome among many others. The primary care provider did a tremendous job to perform an ECG which turned out to be normal. I believe the provider relied on the ECG results to come up with the diagnosis of viral pleurisy. However, it should be noted that about 30% of patients with aortic dissection present with a normal ECG (Patel & Arora, 2017). Additionally, aortic dissection can sometimes combine with myocardial infarction if the dissecting membrane involves the coronary arteries. Therefore, I will not have relied on the results from the ECG to decide on the management of the patient.
Aortic dissection is a relatively uncommon condition that requires analysis of the presenting complaints with the utilization of different diagnostic tools to come up with its diagnosis. The above case scenario only utilized the ECG tool to make an impression of viral pleurisy. Another approach could have been used to aid in the diagnosis of the condition. For instance, there is no specific blood test that can be used to diagnose aortic dissection. However, D-dimer may be used as an exclusive method to rule out aortic dissection and conditions like pulmonary embolism. Performing the test within 24 hours after onset of symptoms can be critical in saving the patient’s life (Kelly et al., 2017). Other definitive diagnostic procedures like CT scan and MRI could have been used to rule out various conditions that present with chest pain.
Advanced nurse practitioners are prepared to provide high-quality patient care by utilizing critical thinking and decision making skills. These skills include the ability to provide care collaboratively and utilizing reflective practice to improve patient outcomes. I believe using a collaborative approach in the case scenario could have helped identify the definitive diagnosis for the patient. It is not clearly indicated whether consultations were made during the care for the patient. Secondly, I believe providing follow-up within 24 hours could have helped identify any health challenges for the patient at home.
Importance of Creating a List of Differentials
When diagnosing medical conditions, the formulation of a list with differentials is important to direct the healthcare provider towards the actual diagnosis. This could have been my primary approach to the above scenario before proceeding to diagnostic tests. Comprehensive health history taking remains the cornerstone of addressing differentials for chest pain which include angina pectoris, typical angina, atypical angina, pleuritic chest pain, noncardiac chest pain, unstable angina, acute coronary syndrome, myocardial infarction, pulmonary embolism, and acute abdominal illness (Kelly et al., 2017). All these conditions have different parameters that guide their diagnosis. Generating differential diagnosis is an aspect of clinical reasoning that advanced nurse practitioners should utilize. These differentials could also guide the number and type of tests to be conducted for a given patient. For instance, the primary care provider should have used a chest x-ray to identify signs of pleurisy. Although pleurisy can be present without accumulation of fluid in the lungs, it could have helped to doubt the existence of another medical condition apart from viral pleurisy.
Using the differential diagnosis approach could have changed the patient outcome because a different approach could have been used to provide treatment. Chest pain is commonly associated with myocardial infarction and basic results from the ECG can rule out the condition. Clinical guidelines for chest pain management recommend suspicion of dissection when symptoms of acute myocardial infarction lack classic ECG changes of MI (Kelly et al., 2017). Using this approach could have led the healthcare provider to look into aortic dissection as a differential for pleurisy. The provider could have noticed that aortic dissection signs are severe at onset and the location of the pain at the chest was an indicator of type 1 or type 2 dissection. Additionally, the healthcare provider could have noticed that type 1 aortic dissection presents with pain in the neck, throat, or jaw as presented in the patient. This differential could also have guided the provider to take blood pressure readings in both arms where a difference in 20mmHg would have suggested aortic dissection. I believe these findings could have guided the healthcare provider into making the right decisions for the management of chest pain in the patient.
Geoffrey R., N., Sandra D., M., Jonathan, S., Jonathan S., I., Henk G., S., & Silvia, M. (2017). The causes of errors in clinical reasoning: Cognitive biases, knowledge deficits, and dual process thinking. Academic Medicine, (1), 23. https://doi.org/10.1097/ACM.0000000000001421
Kelly, C. R., Kirtane, A. J., Stant, J., Stone, G. W., Minutello, R. M., Wong, S. C., Manuzon, H., Gerow-Smith, R., Kelley, N., & Rabbani, L. E. (2017). An updated protocol for evaluating chest pain and managing acute coronary syndromes. Critical Pathways in Cardiology, 16(1), 7–14. https://doi.org/10.1097/HPC.0000000000000098
Patel, P. D., & Arora, R. R. (2018). Pathophysiology, diagnosis, and management of aortic dissection. Therapeutic Advances in Cardiovascular Disease, 2(6), 439-468. https://doi.org/10.1177/1753944708090830
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