As an NP in primary care, what would you have done differently?  I would have completed a more thorough history and physical. More details about events leading up to his symptoms, which are described below. A more thorough physical examination including positional and bilateral vital signs. A more detailed history also described below. This would have led me to a diagnosis of possible aortic dissection, and I would have sent the patient for an emergent MRI and notified the appropriate persons to take over the patient’s care (Schneider et al., 2016).  As recommended by McConaghy (2021), I would have performed a cardiac examination while the patient was lying supine and while sitting up and leaning forward. Classically, patients will have symptom relief with sitting up, and this is also the best position in which to evaluate the patient for a pericardial rub. Evaluation for pulsus paradoxus (an abnormally large decrease in systolic blood pressure [>10 mmHg] on inspiration), which is indicative of cardiac tamponade, should also have been assessed.

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Discuss the importance of creating a list of differentials for this patient. How could it have changed this outcome?  While the patient does exhibit some symptoms congruent with the diagnosis of viral pleurisy, the importance of ruling out other serious causes of the patient’s symptoms cannot be overlooked. Hooshmand et al. (2019) stated that, a differential diagnosis list is the list of possible diagnoses, usually in priority order. One method for the development of a differential diagnosis list is considering the problem from the “skin in.” In the case study example of chest pain, all possible causes of chest pain should be considered beginning at the skin. A visual exam of all the structures in the area that could possibly be affected. Below the skin, the musculoskeletal system (including the rib cage) could be causing pain, from costochondritis or from muscle strain. A pulmonary cause should be considered. Next, is the esophagus. Could the pain be from esophagitis, gastroesophageal reflux, or hiatal hernia? The pericardium is a possible source of pain, as with pericarditis. Finally, consider cardiac pain. Using this approach to create a list of differential diagnoses prevents jumping to early conclusions without considering a wide range of problems. It, thus, avoids the common diagnostic error of premature closure. The differential diagnosis list should always include any conditions that are life, organ, or function threatening.  In this example, a more thorough history and physical along with the creation of a differential diagnosis list likely would have prevented the catastrophic outcome for this patient. Discussion Case Study – Primary Care The Art Of Advance Practice  . If a serious diagnosis comes to mind based on a patient’s symptoms:  Ask yourself: Have you considered the likelihood of a serious diagnosis and whether it needs to be ruled out by testing or referral? Yes, there are many serious diagnoses that present with these symptoms and must be ruled out by testing or referral. As the clinician did in the case study, an ECG would have been a priority, along with possible radiography. Any other testing would require further examination.  Because many serious disorders are challenging to diagnose, have you considered ruling out the worst-case scenario? The provider in the case ruled out an ischemic cause by performing an ECG. Although there are many other life-threatening causes of the patient’s symptoms as evidenced by this case. Labs such as Troponin are often protocol for all patients presenting with chest pain as a brief ECG in the primary care setting is not truly diagnostic of cardiac changes.  Ask yourself: Do you have a sufficient understanding of the clinical presentation to offer an opinion on the diagnosis? The answer is no, more information was required to offer a diagnosis. Did the patient have any signs or symptoms of a virus in the office or recently? The assessment did not indicate the presence of viral symptoms. The sudden onset and short duration point to a non-viral/inflammatory cause. Risk factors need to be explored further, pre-existing conditions, family history, BMI, does he smoke/consume alcohol, exercise, is he diabetic? A patient with one or more of these risk factors will require further testing to rule out serious cardiac diagnoses, even if the patient was previously healthy. jugular venous distension should be assessed. Had the patient eaten recently, was it spicy, greasy, or a large meal? Has the patient been emotionally stressed recently? The assessment mentioned a heart murmur, is this new onset. According to Black & Manning (2021), a cardiac murmur is a possible symptom of aortic dissection and should have been investigated further. Did he do anything strenuous earlier in the day? What medications is he taking? Does he take supplements or consume large amounts of caffeine or other stimulants.  What other diagnoses could it be? How might the treatment to date have altered the patient’s outcome? acute coronary syndrome (ACS) – anginal symptoms at rest, new-onset angina (McConaghy, 2021).  Aortic dissection – is rare but may be a surgical emergency. Patients with acute aortic dissection typically present with acute chest and back pain that is severe and sharp and may have a ripping or tearing quality. Pain can radiate anywhere in the chest or into the abdomen (McConaghy, 2021).  Pulmonary embolism – The most common symptoms of pulmonary embolism include dyspnea followed by pleuritic chest pain and cough (McConaghy, 2021).  Cardiac tamponade – In a patient with pericarditis, development of cardiac tamponade can be life-threatening. Symptoms are sudden in onset and include chest pain, tachypnea, and dyspnea (McConaghy, 2021).  Pericarditis/myopericarditis, Myocarditis – symptoms include sharp, pleuritic chest pain which is decreased by leaning forward from a seated position, and radiates to the trapezius ridge (McConaghy, 2021).  Stress cardiomyopathy – Symptoms, including substernal chest pain, are like that of acute myocardial infarction (McConaghy, 2021).  Malignancy – Patients with lung cancer may complain of chest pain, typically on the same side as the primary tumor. Other symptoms can include cough, hemoptysis, and dyspnea. This diagnosis is unlikely due to the sudden onset of symptoms (McConaghy, 2021).  Esophageal causes would be high on my differential diagnosis list due to the patient’s complaints of sudden onset, non-productive cough, worsened by movement, radiated to base of the neck. Antacids or a GI cocktail (often lidocaine and Maalox) can be administered in the office and the patient can be observed for relief of symptoms, this method is not truly diagnostic but a simple noninvasive test.  Discussion Case Study – Primary Care The Art Of Advance Practice.   GERD – Chest pain due to GERD can mimic angina pectoris and may be described as squeezing or burning, located substernal and radiating to the back, neck, jaw, or arms. It can last minutes to hours and resolves spontaneously or with antacids. It may occur after meals, awaken patients from sleep, and be exacerbated by emotional stress (McConaghy, 2021).  Other – Hiatus hernias may cause chest pain, acute cholecystitis, biliary colic, and pancreatitis may have pain that involves the chest (McConaghy, 2021).  Psychiatric and drug use – are also possible causes (McConaghy, 2021).  Aortic dissection is on the differential diagnosis list and had the patient been assessed for this he may have had a different outcome. Also, investigation into many of these differential diagnoses may have led to the more serious diagnosis as well.  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? McConaghy (2021) reported Indications for a chest radiograph include suspected pulmonary causes of chest pain, heart failure or rib fracture. In this case the patient should have had a chest x-ray.  McConaghy (2021) stated that, if symptoms are concerning for aortic dissection (acute chest and back pain that is severe, sharp, with a ripping or tearing quality), blood pressure should be obtained in both arms.     Are you familiar with the current clinical practice guidelines for the investigation of a suspected condition such as chest pain? Clinical practice guidelines should be obtained from national organizations such as The American Heart Association and American Collage of Cardiology. Resources such as UpToDate offer evidence-based clinical decision support by compiling national data into peer reviewed research articles. Discussion Case Study – Primary Care The Art Of Advance Practice