Relying solely on the classic features of a disease may be misleading. That’s because the clinical presentation of a disease often varies: the symptoms and signs of many conditions are non-specific initially and may require hours, days, or even months to develop. Generating a differential diagnosis; that is, developing a list of the possible conditions that might produce a patient’s symptoms and signs — is an important part of clinical reasoning. It enables appropriate testing to rule out possibilities and confirm a final diagnosis. 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. As an NP in primary care what would you have done differently? 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?

Creating a comprehensive list of differential diagnoses is a critical step in the process of clinical reasoning and can significantly impact patient outcomes. In the case of the previously healthy 35-year-old lawyer presenting with chest pain and a non-productive cough, the initial diagnosis of viral pleurisy and subsequent treatment with non-steroidal analgesics may not have been appropriate given the eventual diagnosis of a Type 1 aortic dissection with pericardial tamponade.

As an NP in primary care, it is important to approach every patient with a broad and open mindset, considering all potential diagnoses, especially for presentations that may indicate a serious condition. Chest pain is a symptom that can be associated with a wide range of conditions, including both benign and life-threatening ones. By creating a comprehensive list of possible differential diagnoses, NP can ensure that they have considered all relevant possibilities before making a final diagnosis.

In this particular case, the list of differential diagnoses for a patient presenting with chest pain and a non-productive cough should have included conditions such as acute coronary syndrome, pulmonary embolism, pneumothorax, esophageal rupture, pericarditis, and aortic dissection, among others. These are all potential causes of chest pain that can have serious implications if not promptly and accurately diagnosed.

Considering the likelihood of each potential diagnosis is crucial in determining the appropriate course of action. Serious conditions like aortic dissection should be high on the list of differential diagnoses given the nature of the patient’s symptoms, such as the sudden onset and sharp pain worsened by movement and inspiration. Ruling out the worst-case scenario is essential in preventing adverse outcomes. In this case, aortic dissection should have been considered and investigated further through appropriate testing or referral.

To create a comprehensive differential diagnosis list, NP should have a good understanding of the clinical presentation of each potential condition. They should be able to identify the key features and distinguishing characteristics of each diagnosis to make an informed decision. Consultation with other healthcare professionals, such as cardiologists or radiologists, may be necessary to analyze and interpret certain diagnostic tests or imaging studies.

In terms of additional diagnostic and laboratory imaging needed, an ECG alone may not always be sufficient to rule out serious cardiac or vascular conditions. In this case, further imaging studies such as a computed tomography angiography (CTA) or magnetic resonance angiography (MRA) could have been considered to investigate the possibility of an aortic dissection. Laboratory tests to assess cardiac enzymes, D-dimer levels, and inflammatory markers may also have provided valuable information to support or exclude certain diagnoses.

Support tools can aid in the creation of a differential diagnosis list. Clinical decision support systems (CDSS) and electronic medical record systems often include tools and resources that provide evidence-based guidance and recommendations. These tools can help NP to consider a broader range of diagnoses and to ensure adherence to current clinical practice guidelines.

Familiarity with clinical practice guidelines for the investigation of suspected conditions, such as chest pain, is essential for NP in primary care. These guidelines are based on the best available evidence and provide a standardized approach to the evaluation and management of patients. By following these guidelines, NP can ensure that appropriate investigations are undertaken, and potential serious conditions are not missed.

In conclusion, the importance of creating a comprehensive list of differential diagnoses cannot be overstated. This process helps to consider all potential possibilities and ensures that no serious conditions are overlooked. In the case of the 35-year-old lawyer with chest pain and a non-productive cough, a more extensive list of differential diagnoses, including aortic dissection, should have been considered. This could have led to further investigation and appropriate management, potentially altering the patient’s outcome. NP must have a solid understanding of clinical presentations, utilize support tools, and adhere to clinical practice guidelines to provide the best possible care for their patients.