Poor Patient Outcome

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.

Case scenario

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.

Written Assignment:

Developing a list of possible conditions that might produce a patient’s symptoms and signs is an important part of clinical reasoning.

1. As an NP in primary care what would you have done differently?
2. 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?
• 5 pages

 

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Choose one evidence-based practice that you see yourself using as a provider in your clinical practice and discuss how it meets the listed benefits.

Why should we, as healthcare providers, use evidence-based practice?

Evidence-based practice benefits:

• Leads to highest quality care and patient outcomes
• Reduces health care costs
• Reduces geographic variations in the delivery of care
• Increases healthcare provider empowerment and role satisfaction
• Reduces healthcare provider turnover rate
• Increases reimbursement from 3rd party payers
• Reduces complications and payment denials
• Meets the expectation of an informed public

Include 3 evidence-based articles to support your work that are less than 3 years old.

Before finalizing your work, you should:

• be sure to read the Assignment description carefully (as displayed above);
• consult the Grading Rubric (under the Course Home) to make sure you have included everything necessary; and
• utilize spelling and grammar check to minimize errors.   4 pages not including title and reference pages

 

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Tuberculosis

M. tuberculosis can be transmitted in virtually any setting. Clinicians should be aware that transmission has been documented in healthcare settings where healthcare workers and patients come in contact with persons with infection.

• Describe the factors that determine the infectiousness of a tuberculosis (TB) patient;

• Explain the main goals of a TB infection control program;

• Discuss the three levels of an effective TB infection control program;

• Explain the purpose and the characteristics of a TB airborne infection isolation room; and

• Describe the circumstances when respirators and surgical masks should be used.

2 pages not including title and reference page

 

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Tina is 5 years old, lives with her mother and grandmother. Mother works 2 jobs to help support her mother and her daughter. Tina is well cared for but is now admitted for a cardiac catheterization due to the Ventricular Septal Defect (VSD) that was noted at birth.

Tina has an extensive history of respiratory infections and a nursing diagnosis of ‘activity intolerance’. Her mother relates that she does not allow her to play organized or competitive games due to her health. Tina smiles broadly when you come in the room to begin the pre-operative checklist. She starts to ask you a question when her grandmother tells her she must stay in the bed. “The nurse knows what she is doing and you will just be in the way.” Tina continues to smile at you but moves back to the bed.

You have identified some unique family dynamics, please relate.

What is the Erikson developmental level that Tina should exhibit? 

And where do you think she is?

How can you assist in the developmental growth?

What education can you give to Tina and her grandmother pre operatively?

What will she expect post operatively?

300 words

 

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