Worsening chest pain

Activity summary

This text case portrays a poor patient outcome after a misdiagnosis. The facilitation questions and suggestions to faculty help learners consider common problems related to the diagnostic process.

Case scenario

A previously healthy 35-year-old male presents to the emergency department with a chief complaint of chest pain and a non-productive cough. The pain began about 2 hours earlier while the patient was watching television. The patient describes the pain as sharp in nature, constantly present but made worse with inspiration and movement, and radiating to the base of the neck. Vital signs taken at triage are normal. 

On physical examination, the only findings of note are chest wall tenderness and a faint cardiac murmur. The ECG and chest X-ray are reported as normal, as are cardiac biomarkers and a D-dimer test. Point-of-care ultrasound is unavailable. No other investigations are performed. The patient is kept under observation for several hours and treated with intravenous opioid analgesics. Despite treatment, he reports no change in his pain. Given the lack of a definitive diagnosis, the emergency physician refers the patient to the internal medicine service just prior to finishing her shift. The incoming emergency physician is informed of the pending consultation and does not assess the patient. 

Several hours later, the patient is assessed by the internal medicine resident who considers the likely diagnosis is viral pleurisy. The resident reviews the case over the phone with the attending physician, who concurs with the diagnosis. The patient is subsequently discharged from the emergency department with a prescription for a non-steroidal analgesic. 

The following day the patient collapses at home, and resuscitative efforts by the paramedics are unsuccessful. An autopsy reveals a Type A aortic dissection with pericardial tamponade.

Facilitation questions

1. What are some factors in this case that may have led to the diagnosis being missed?
2. What are some clinical “red flags” in this case that might have helped identify a life-threatening condition?
3. What else might prompt a diagnosis to be reconsidered?
4. In the absence of any additional clinical information, what would you have included in the discharge instructions to the patient?

Suggestions to faculty

This text case can also be used to consider the CMPA Good practices, “Physician-patient: Informed discharge”. For example, ask learners to identify the key information that should have been provided to the patient. What other follow-up, if any, should have occurred?

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