This text case describes a missed diagnosis. The facilitation questions and suggestions to faculty focus on helping learners to understand common challenges to establishing a diagnosis.
A healthy 27-year-old non-English speaking male falls in the bathtub and injures his right side. After the fall, he has mild right-sided pleuritic chest pain and point tenderness over the right lower chondral rib margin. The pain is not debilitating and he is able to pursue his usual activities.
Three days later, while watching television, the pain suddenly becomes worse and spreads across his entire chest. He feels short of breath, and his wife notices that he is pale and sweating so she calls an ambulance. Upon the arrival of the paramedics, the patient appears agitated and is in moderate distress. Both the patient and his wife have very limited English language skills. Using the wife as interpreter, the paramedics obtain his history including the fall 3 days previously. Vital signs are within normal limits and chest auscultation and palpation are normal. The paramedics decide to transport the patient to the hospital. Their diagnostic impression is a musculoskeletal injury with overlying anxiety.
On arrival at a tertiary care hospital, the triage nurse speaks to the paramedics and briefly assesses the patient. She records the chief complaint and history of present illness as follows: "right-sided rib pain, fall in bathtub 3 days ago, now right-sided pleuritic chest pain, ? anxiety." The patient is triaged to the ambulatory care area of the emergency department. The patient is then assessed again by the ambulatory care nurse who records: "right-sided rib pain, fall in bathtub 3 days ago, now right-sided pleuritic chest pain, ? anxiety." The vital signs are repeated and are normal.
Shortly thereafter, the patient is seen by a PGY1 on the first day of his emergency rotation. Using the wife as interpreter, the resident obtains a history that is consistent with the history obtained by the paramedics. The physical examination demonstrates equal air entry, no subcutaneous air, a benign abdomen, and point tenderness over the lower right chondral ribs. Documentation includes: "right-sided rib pain, fall in bathtub 3 days ago, now worsening right-sided pleuritic chest pain." The resident discusses the case with the attending physician and they decide to discharge the patient with a prescription for analgesics. No further investigations are performed.
After being discharged, the patient's chest pain persists for the next 24 hours. As the pain begins to subside, the patient notes increasing shortness of breath upon exertion. Two days after discharge he presents to his family physician with a pulse of 125, BP 85/60, RR 26, and SpO2 85% on room air. There are crepitations in both lung fields at the level of the scapula and a gallop rhythm is identified. The family physician, who is fluent in the patient's mother tongue, is able to establish that the pain experienced by the patient on the day of the emergency visit was much more severe and different than the initial pain post-fall.
The patient is referred to the emergency department where an ECG shows an extensive anterior myocardial infarction with ST elevation and large Q waves. Given the temporal sequence of events, thrombolytics are not given. Two days post admission, a cardiac catheterization shows a complete occlusion of his circumflex artery. His ejection fraction post discharge is 25% and a large left ventricular aneurysm is demonstrated on echocardiogram.
The patient is unable to return to his previous work as a manual labourer.
- Describe some of the factors that prevented the healthcare providers from entertaining a wider differential diagnosis.
- What are some strategies for dealing with these factors?
- Did the anxiety label have an impact on patient care? Discuss.
Suggestions to faculty
This text case may also be used to explore “The healthcare system: Human factors”, CMPA Good practices. For example, ask learners to consider how the following cognitive biases may have influenced patient care: anchoring, confirmation bias, diagnostic momentum, and premature closure. Are there any other cognitive or affective biases that may have influenced patient care in this scenario?