A previously healthy 35-year-old lawyer arrives at a primary care office complaining of chest pain and a non-productive cough. The pain began suddenly two hours before the patient arrived at the office, while he was sitting at his desk. The patient describes the pain as sharp, constant, but exacerbated by inspiration and movement, and radiating to the base of the neck. His blood pressure in his right arm is normal, as are his other vital signs.

In terms of physical

The only notable findings on examination are chest wall tenderness and a faint cardiac murmur. In the office, the ECG is normal. The patient is assessed and observed in the office for an hour. He is diagnosed with viral pleurisy and is given nonsteroidal analgesics to take home.

The patient collapses at home the next day and cannot be resuscitated by the paramedic service. An autopsy reveals that the patient died of a Type 1 aortic dissection with pericardial tamponade.

Assignment in writing:

Creating a list of potential conditions that could cause a patient’s symptoms and signs is an important part of the diagnostic process.

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As a primary care nurse practitioner

Interested in what you would have done differently?
Discuss the significance of developing a differential diagnosis list for this patient. How could it have influenced the outcome?
If a serious diagnosis is suggested by a patient’s symptoms:

Have you considered the possibility and whether it needs to be ruled out through testing or referral?
Have you considered ruling out the worst-case scenario because many serious disorders are difficult to diagnose?
Do you have a good enough understanding of the clinical presentation to offer an opinion on the diagnosis?

Could it be something else? How might the current treatment have influenced the patient’s outcome?
What other diagnostic, laboratory, or imaging tests were required to create a complete differential list? What assistance tools would you consider using to assist in the creation of a differential diagnosis list?
Are you familiar with the most recent clinical practice guidelines for investigating a suspected condition like chest pain?

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