Delay in diagnosis of myocardial infarction

Activity summary

This case describes a missed myocardial infarction in a middle-aged male patient. The facilitation questions and suggestions focus on helping learners recognize their biases, and the risks around discharge planning in situations where a diagnosis may be unclear.

Case scenario

A 55-year-old patient complaining of right shoulder pain is seen in an outpatient clinic. He says the pain began when he was carrying heavy boxes upstairs a few hours earlier. He complains of pain and requests a prescription for opioids several times during the clinical encounter. On examination, the physician notes some limitation in range of motion of the right shoulder and tenderness over the chest wall. After examining the patient for a rotator cuff injury, the physician feels that the patient likely has a partial supraspinatus tear. The patient is referred to physiotherapy, and advised to rest and take over-the-counter analgesia for the pain. The patient, who has a past history of opioid use disorder, becomes very upset after the physician explains their rationale for not prescribing an opioid. The patient is offered a follow-up appointment in 3 weeks.

Two days later, the patient arrives by ambulance at the emergency department after midnight. He is triaged as ‘Right shoulder injury 2 days ago. Requesting analgesia'. The patient is triaged to a non-urgent area of the department and not seen by a physician for several hours. Eventually, an ECG is performed and shows changes consistent with a subacute myocardial infarction. Despite treatment, the patient is left with a poor left ventricular ejection fraction and functional limitations.

Facilitation questions

1. What biases or human factors may have contributed to the delay in diagnosis?
2. What strategies could help counter biases?
3. Could the use of a diagnostic reasoning tool such as FOAM have helped the physician consider other diagnoses during the initial visit?
4. How can the documentation of differential diagnoses assist with the diagnostic process?
5. Discuss the medico-legal importance of documentation for cases in which the diagnosis is not initially clear.
6. What type of information should typically be included in discharge instructions provided to patients, and how would you best document those conversations?

Suggestions to faculty

This text case may also be used when considering the CMPA good practices, “The healthcare system: Human factors” and “Physician-patient: Clinical decision-making”. For example, how did the patient's shoulder injury bias the clinical decision-making of the emergency physician? What other patient factors may have influenced the emergency physician's diagnosis?

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.