Peer Response – Evaluating Differential Diagnoses for a 55-Year-Old Male with Leg Pain and a History of Gout

Peer Response – Evaluating Differential Diagnoses for a 55-Year-Old Male with Leg Pain and a History of Gout

Responding to Nichole Pearce

Hey Nichole, well done! Your work is well-detailed, structured, and adequately answers the questions. I agree with you that the information provided cannot really come up with an accurate list of differentials. However, using the available information, possible differential diagnoses include deep venous thrombosis, Baker’s cyst, cellulitis, and gout flare-up with secondary infection or cellulitis (American Academy of Family Physicians, 2024). I also concur that one could question possible tibial fractures if there was a positive trauma history; therefore, more information from the patient would help come up with a differential diagnosis.

On the issue of the provider’s legal liability to explain diagnostics, I agree with you that they are legally liable. Informed consent is an important medical practice aspect that ensures that patients are well versed with the drive, benefits, risks, and alternatives of any other treatments or tests. Failure to provide adequate information to the patient on the diagnostics can result in legal repercussions if the patient encounters an injury as a result (Bono & Hipskind, 2019).

Your discussion also notes different missed opportunities that Esteban could have addressed, which could have possibly led to a different outcome. To add to your list, I view not putting DVT into consideration as a possible primary differential diagnosis even though there are significant risk factors and symptoms noted in the patient, including immobility due to pain and gout history (American Academy of Family Physicians, 2024). Also, the provider failed to delay the ultrasound despite the patient’s symptoms worsening. I share the same sentiments with you about suing Esteban. However, I would also take into consideration if Esteban met the required standard of care if his actions directly caused the death of the patient or contributory negligence by the patient for not seeking immediate medical attention (Bono & Hipskind, 2019).

Thank you.

References

American Academy of Family Physicians. (2024). Diagnosis of Venous Thromboembolism – Clinical Practice Guideline. Www.aafp.org. https://www.aafp.org/family-physician/patient-care/clinical-recommendations/all-clinical-recommendations/venous-thromboembolism-diagnosis.html

Bono, M. J., & Hipskind, J. E. (2019). Medical malpractice. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470573/

Responding to Siranush Grigoryan

Hello Siranush,

Superb work you have done here! As you have noted in your discussion, possible differential diagnosis includes DVT, Baker’s cyst, and gout flare-up. However, cellulitis could also be a possible differential diagnosis. Cellulitis also presents with similar symptoms like tenderness, warmth, and redness in the affected region. Also, the provider should have noted a tibial fracture, which may have caused similar symptoms (CDC, 2022). It is prudent to note that the history provided was not enough to make a complete differential diagnosis. I agree that the provider is legally liable to explain the diagnostics ordered to the patient. Informed consent is the primary principle in healthcare. It ensures that patients are conversant with the benefits, risks, purpose, and other possible treatments and tests. As you have mentioned, inadequate information about the patient may cause ethical and legal issues (Dahlawi et al., 2021).

Further, your discussion has also noted three missed opportunities by the provider that might change the treatment outcome. Apart from the three, I think the provider also showed no urgency in noting the seriousness of the situation when the calf of the patient continued to swell despite the treatment (Dahlawi et al., 2021). I agree with you that Esteban should be sued. The nurse practitioner deviated from the standard of care by not considering DVT as a primary diagnosis, delayed in asking for the right diagnostic tests, and showed no urgency when the symptoms of the patient worsened (Dahlawi et al., 2021). This case highlights the need for detailed differential diagnosis, effective communication with patients about treatment and diagnostic plans, noting the urgency of specific medical situations, and understanding the legal implications and responsibilities of healthcare providers.

References

CDC. (2022, June 9). Diagnosis and treatment of venous thromboembolism. Centers for Disease Control and Prevention. https://www.cdc.gov/ncbddd/dvt/diagnosis-treatment.html

Dahlawi, S., Menezes, R. G., Khan, M. A., Waris, A., Saifullah, & Naseer, M. M. (2021). Medical negligence in healthcare organizations and its impact on patient safety and public health: A bibliometric study. F1000Research, 10(1), 1–15. https://doi.org/10.12688/

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Discuss the appropriate differential diagnoses for this patient.

More information is needed to make an accurate list of differentials. Based on the limited information in the case study, a 55-year-old male with a history of Gout presents with leg pain, differentials for this patient might include Gout, DVT, Baker cyst, cellulitis, or tibial fracture. The case study does not give details about the patient’s lifestyle, or medical history other than Gout or if any injury occurred. We also do not know what medications he is currently taking or his family history. All of these things might change our list of differential diagnoses.

Peer Response – Evaluating Differential Diagnoses for a 55-Year-Old Male with Leg Pain and a History of Gout

2.Is the provider legally liable to explain to the patient the diagnostics that they are ordering? Why?

Yes. The patient should be informed about all aspects of their healthcare. Patients should understand what tests are being done and why they are being performed. Patients have the right to consent to or refuse any treatment or testing. Informed consent means that the patient understands the risks, benefits and alternatives to treatment.

3.How many missed opportunities did Esteban have?

I think Esteban should have sent the patient for labs and Ultrasound at the initial visit. The Wells Scoring should have been used to determine DVT risk and treatment. Even if the wells Score was zero, and DVT was not suspected at the time, the patient should have been educated on signs and symptoms of DVT including increased pain, swelling, warmth or redness to the extremity and going to the ER if any of these symptoms occur. He should have been educated that late signs of DVT include trouble breathing or chest pain and in these cases he should call 911. If he had been educated about these symptoms he likely would have went to the ER, rather than waiting at home with worsening symptoms for 3 weeks. At the second visit when he arrived with obvious swelling to one calf, EMS should have been called to transport the patient to the ER. There was no sense of urgency, even when the patient presented with multiple symptoms suggesting DVT.

4.Should Esteban be sued? Why or why not?

I think this is a personal choice for the family. The result may have been the same even if early diagnosis and treatment were started, but in this case, we will not know. If the family feels that Esteban did not take the appropriate measures in treating the patient, then they have the right to sue. As a future provider, I do not think that Esteban meant any harm to the patient, but he could have taken the patient’s complaints more seriously.  Personally, I would also want to sue because the Practice Guidelines for DVT were not followed. There were multiple missed opportunities to correctly diagnose this patient and start him on the appropriate treatment regimen that may have saved his life.