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.
This case portrays a poor patient outcome after a misdiagnosis.
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 tampon.
Developing a list of possible conditions that might produce a patient’s symptoms and signs is an important part of clinical reasoning.