scholarly journals Lessons in clinical reasoning – pitfalls, myths, and pearls: a case of chest pain and shortness of breath

Diagnosis ◽  
2019 ◽  
Vol 6 (4) ◽  
pp. 387-392
Author(s):  
McCall Walker ◽  
Karen M. Warburton ◽  
Joseph Rencic ◽  
Andrew S. Parsons
Keyword(s):  
Chest Pain ◽  
Clinical Reasoning ◽  
Elevated Serum ◽  
Diagnostic Errors ◽  
Diagnostic Error ◽  
Human Cognition ◽  
Shortness Of Breath ◽  
Coronary Syndrome ◽  
Premature Closure ◽  
Submassive Pulmonary Embolism

Abstract Background Defects in human cognition commonly result in clinical reasoning failures that can lead to diagnostic errors. A metacognitive structured reflection on what clinical findings fit and/or do not fit with likely and “can’t miss” diagnoses may reduce such errors. Case presentation A 57-year-old man was sent to the emergency department from clinic with chest pain, severe shortness of breath, weakness, and cold sweats. Further investigation revealed multiple risk factors for coronary artery disease, sudden onset of exertional dyspnea, and chest pain that incompletely resolved with rest, mild tachycardia and hypoxia, an abnormal electrocardiogram (ECG), elevated serum cardiac biomarkers, and elevated B-type natriuretic peptide (BNP) in the absence of left-sided heart failure. He was treated for acute coronary syndrome (ACS), discharged, and quickly returned with worsening symptoms that eventually led to a diagnosis of submassive pulmonary embolism (PE). Conclusions Through integrated commentary on the diagnostic reasoning process from clinical reasoning experts at two institutions, this case underscores the importance of frequent assessment of fit along with explicit explanation of dissonant features in order to avoid premature closure and diagnostic error. A fishbone diagram is provided to visually demonstrate the major factors that contributed to the diagnostic error. A case discussant describes the importance of diagnostic schema as an analytic reasoning strategy to assist in the creation of a differential diagnosis, problem representation to summarize updated findings, a Popperian analytic approach of attempting to falsify less-likely hypotheses, and matching pertinent positives and negatives to previously learned illness scripts. Finally, this case provides clinical teaching points in addition to a pitfall, myth, and pearl specific to premature closure.

Lessons in clinical reasoning ‒ pitfalls, myths, and pearls: a case of confusion, disequilibrium, and “picking at the air”

Diagnosis ◽  
2021 ◽  
Vol 0 (0) ◽  
Author(s):  
Charles D. Magee ◽  
Andrew S. Parsons ◽  
Alexander S. Millard ◽  
Dario Torre
Keyword(s):  
Clinical Reasoning ◽  
Cognitive Biases ◽  
Diagnostic Errors ◽  
Diagnostic Error ◽  
Human Cognition ◽  
Case Presentation ◽  
Fishbone Diagram ◽  
Major Factors ◽  
Medication Changes ◽  
Incision Drainage

Abstract Objectives Defects in human cognition commonly result in clinical reasoning failures that can lead to diagnostic errors. Case presentation A 43-year-old female was brought to the emergency department with 4–5 days of confusion, disequilibrium resulting in several falls, and hallucinations. Further investigation revealed tachycardia, diaphoresis, mydriatic pupils, incomprehensible speech and she was seen picking at the air. Given multiple recent medication changes, there was initial concern for serotonin syndrome vs. an anticholinergic toxidrome. She then developed a fever, marked leukocytosis, and worsening encephalopathy. She underwent lumbar puncture and aspiration of an identified left ankle effusion. Methicillin sensitive staph aureus (MSSA) grew from blood, joint, and cerebrospinal fluid cultures within 18 h. She improved with antibiotics and incision, drainage, and washout of her ankle by orthopedic surgery. Conclusions Through integrated commentary on the diagnostic reasoning process from clinical reasoning experts, this case underscores how multiple cognitive biases can cascade sequentially, skewing clinical reasoning toward erroneous conclusions and driving potentially inappropriate testing and treatment. A fishbone diagram is provided to visually demonstrate the major factors that contributed to the diagnostic error. A case discussant describes the importance of structured reflection, a tool to promote metacognitive analysis, and the application of knowledge organization tools such as illness scripts to navigate these cognitive biases.

Lessons in clinical reasoning – pitfalls, myths, and pearls: the contribution of faulty data gathering and synthesis to diagnostic error

Diagnosis ◽  
2021 ◽  
Vol 0 (0) ◽  
Author(s):  
Martin A. Schaller-Paule ◽  
Helmuth Steinmetz ◽  
Friederike S. Vollmer ◽  
Melissa Plesac ◽  
Felix Wicke ◽  
...  
Keyword(s):  
Patient Safety ◽  
Clinical Reasoning ◽  
Data Gathering ◽  
Diagnostic Errors ◽  
Diagnostic Error ◽  
Care Physician ◽  
Diagnostic Process ◽  
Myasthenic Crisis ◽  
Hospital Organization ◽  
Substantial Impact

Abstract Objectives Errors in clinical reasoning are a major factor for delayed or flawed diagnoses and put patient safety at risk. The diagnostic process is highly dependent on dynamic team factors, local hospital organization structure and culture, and cognitive factors. In everyday decision-making, physicians engage that challenge partly by relying on heuristics – subconscious mental short-cuts that are based on intuition and experience. Without structural corrective mechanisms, clinical judgement under time pressure creates space for harms resulting from systems and cognitive errors. Based on a case-example, we outline different pitfalls and provide strategies aimed at reducing diagnostic errors in health care. Case presentation A 67-year-old male patient was referred to the neurology department by his primary-care physician with the diagnosis of exacerbation of known myasthenia gravis. He reported shortness of breath and generalized weakness, but no other symptoms. Diagnosis of respiratory distress due to a myasthenic crisis was made and immunosuppressive therapy and pyridostigmine were given and plasmapheresis was performed without clinical improvement. Two weeks into the hospital stay, the patient’s dyspnea worsened. A CT scan revealed extensive segmental and subsegmental pulmonary emboli. Conclusions Faulty data gathering and flawed data synthesis are major drivers of diagnostic errors. While there is limited evidence for individual debiasing strategies, improving team factors and structural conditions can have substantial impact on the extent of diagnostic errors. Healthcare organizations should provide the structural supports to address errors and promote a constructive culture of patient safety.

Lessons in clinical reasoning ‒ pitfalls, myths and pearls: a case of recurrent pancreatitis

Diagnosis ◽  
2021 ◽  
Vol 0 (0) ◽  
Author(s):  
Vita Jaspan ◽  
Verity Schaye ◽  
Andrew S. Parsons ◽  
David Kudlowitz
Keyword(s):  
Acute Pancreatitis ◽  
Clinical Reasoning ◽  
Cognitive Biases ◽  
Diagnostic Errors ◽  
Diagnostic Error ◽  
First Episode ◽  
Gut Flora ◽  
Case Presentation ◽  
Early Hypothesis ◽  
Elevated Transaminases

Abstract Objectives Cognitive biases can result in clinical reasoning failures that can lead to diagnostic errors. Autobrewery syndrome is a rare, but likely underdiagnosed, condition in which gut flora ferment glucose, producing ethanol. It most frequently presents with unexplained episodes of inebriation, though more case studies are necessary to better characterize the syndrome. Case presentation This is a case of a 41-year old male with a past medical history notable only for frequent sinus infections, who presented with recurrent episodes of acute pancreatitis. In the week prior to his first episode of pancreatitis, he consumed four beers, an increase from his baseline of 1–2 drinks per month. At home, he had several episodes of confusion, which he attributed to fatigue. He underwent laparoscopic cholecystectomy and testing for genetic and autoimmune causes of pancreatitis, which were non-revealing. He was hospitalized 10 more times during that 9-month period for acute pancreatitis with elevated transaminases. During these admissions, he had elevated triglycerides requiring an insulin drip and elevated alcohol level despite abstaining from alcohol for the prior eight months. His alcohol level increased after consumption of complex carbohydrates, confirming the diagnosis of autobrewery syndrome. Conclusions Through integrated commentary on the diagnostic reasoning process, this case underscores how overconfidence can lead to premature closure and anchoring resulting in diagnostic error. Using a metacognitive overview, case discussants describe the importance of structured reflection and a standardized approach to early hypothesis generation to navigate these cognitive biases.

Checklists to prevent diagnostic errors: a pilot randomized controlled trial

Diagnosis ◽  
2015 ◽  
Vol 2 (3) ◽  
pp. 163-169 ◽  
Author(s):  
John W. Ely ◽  
Mark A. Graber
Keyword(s):  
Primary Care ◽  
Usual Care ◽  
Error Rate ◽  
Primary Care Physicians ◽  
Diagnostic Errors ◽  
Diagnostic Error ◽  
Diagnostic Process ◽  
Emergency Physicians ◽  
Mean Error ◽  
Premature Closure

AbstractMany diagnostic errors are caused by premature closure of the diagnostic process. To help prevent premature closure, we developed checklists that prompt physicians to consider all reasonable diagnoses for symptoms that commonly present in primary care.We enrolled 14 primary care physicians and 100 patients in a randomized clinical trial. The study took place in an emergency department (5 physicians) and a same-day access clinic (9 physicians). The physicians were randomized to usual care vs. diagnostic checklist. After completing the history and physical exam, checklist physicians read aloud a differential diagnosis checklist for the chief complaint. The primary outcome was diagnostic error, which was defined as a discrepancy between the diagnosis documented at the acute visit and the diagnosis based on a 1-month follow-up phone call and record review.There were 17 diagnostic errors. The mean error rate among the seven checklist physicians was not significantly different from the rate among the seven usual-care physicians (11.2% vs. 17.8%; p=0.46). In a post-hoc subgroup analysis, emergency physicians in the checklist group had a lower mean error rate than emergency physicians in the usual-care group (19.1% vs. 45.0%; p=0.04). Checklist physicians considered more diagnoses than usual-care physicians during the patient encounters (6.5 diagnoses [SD 4.2] vs. 3.4 diagnoses [SD 2.0], p<0.001).Checklists did not improve the diagnostic error rate in this study. However further development and testing of checklists in larger studies may be warranted.

scholarly journals Fitting a Square Peg in a Round Hole: A Simple Case of Chest Pain

2020 ◽  
Vol 4 (1) ◽  
pp. 1-7
Author(s):  
Mary McLean ◽  
Jennifer Beck-Esmay
Keyword(s):  
Risk Factors ◽  
Chest Pain ◽  
Young Women ◽  
Point Of Care ◽  
Round Hole ◽  
Shortness Of Breath ◽  
Cardiac Enzymes ◽  
Coronary Syndrome ◽  
St Elevation ◽  
Atherosclerotic Risk Factors

A 39-year-old female presents to the emergency department with chest pain and shortness of breath. Her electrocardiogram suggests ST-elevation myocardial infarction, but she has no atherosclerotic risk factors. She is gravida 4, para 4, and four weeks postpartum from uncomplicated vaginal delivery. She is diaphoretic and anxious, but otherwise her exam is unremarkable. Cardiac enzymes are markedly elevated and point-of-care echocardiogram shows inferolateral hypokinesis and ejection fraction of 50%. In this clinicopathological case, we explore a classically underappreciated cause of acute coronary syndrome in healthy young women.

scholarly journals Patterns of Emergency Care for Possible Acute Coronary Syndrome Among Patients with Chest Pain or Shortness of Breath at a Tanzanian Referral Hospital

Global Heart ◽  
2020 ◽  
Vol 15 (1) ◽  
pp. 9 ◽  
Author(s):  
Julian T. Hertz ◽  
Godfrey L. Kweka ◽  
Gerald S. Bloomfield ◽  
Alexander T. Limkakeng ◽  
Zak Loring ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Chest Pain ◽  
Emergency Care ◽  
Referral Hospital ◽  
Shortness Of Breath ◽  
Coronary Syndrome

Presenting characteristics of patients undergoing cardiac troponin measurements in the emergency department

CJEM ◽  
2015 ◽  
Vol 17 (1) ◽  
pp. 62-66 ◽  
Author(s):  
Daniel A. Goodman ◽  
Peter A. Kavsak ◽  
Stephen A. Hill ◽  
Andrew Worster
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Elderly Patients ◽  
Cardiac Troponin ◽  
Patient Characteristics ◽  
The Elderly ◽  
Primary Objective ◽  
Shortness Of Breath ◽  
Coronary Syndrome ◽  
Secondary Objective

AbstractIntroductionNot all patients with suspected acute coronary syndrome (ACS) receiving cardiac troponin (cTn) testing present to the emergency department (ED) with cardiac chest pain. Since elderly patients (age ≥70) have increased morbidity and mortality associated with ACS, complaints other than cardiac chest pain may justify cTn testing. Our primary objective was to characterize the population of ED patients who receive cTn testing. The secondary objective was to determine if elderly patients underwent cTn testing for different presenting complaints than their younger counterparts.MethodsWe created an electronic database including Canadian Emergency Department Information Systems (CEDIS) presenting complaints, age, sex, disposition, and Canadian Triage Acuity Scale (CTAS) score, for patients who received cTn testing in three Canadian EDs during 2011. We analyzed the data for patient characteristics and sorted by age (<70 and ≥70) for further analysis.ResultsIn the 15,824 included patients, the average age was 66 (51%<70; 51% female). The most common presenting complaints were cardiac chest pain (n=3,267) and shortness of breath (n=2,266). The elderly underwent cTn testing for significantly (p<0.0001) different complaints than their younger counterparts. They more commonly presented with generalized weakness (n=898), whereas younger patients more frequently had abdominal pain (n=576).ConclusionsCardiac chest pain and shortness of breath are presenting complaints in one-third of patients undergoing ED cTn testing. The majority of patients undergoing cTn testing did not have typical ACS symptoms. Half of all cTn testing in the ED is on the elderly, who present with different complaints than their younger counterparts.

scholarly journals Diagnostic findings in patients with chest pain, cough, and shortness of breath during the COVID-19 pandemic: what else besides pneumonia?

2021 ◽  
Vol 65 (1) ◽  
pp. 24-29
Author(s):  
Dmitriy A. Doroshenko ◽  
Yuriy I. Rumyantsev ◽  
Oksana A. Shapsigova ◽  
Natalya A. Sokolova ◽  
Lev L. Klykov ◽  
...  
Keyword(s):  
Chest Pain ◽  
Acute Chest Pain ◽  
Shortness Of Breath ◽  
Coronary Syndrome ◽  
Single Center Study ◽  
Pulmonary Manifestations ◽  
Stage Of Diagnosis ◽  
Peripheral Lung ◽  
Risk Patients ◽  
Radiographic Changes

Purpose. Description and illustration of the most common alternative causes of shortness of breath, cough, and acute chest pain in pandemic COVID-19 conditions. Material and methods. Authors evaluated results of the retrospective single-center study and instrumental data of 67 patients with complaints of sudden chest pain, cough and shortness of breath. For patients admitted to the hospital between March, 27 and June, 30, 2020, the first stage of diagnosis was made with the performed multispiral computed tomography (MSCT) of the chest, confirming the presence of pulmonary manifestations of COVID-19. The study did not include patients with pneumothorax identified at the pre - and hospital stages. We describe early radiographic changes in the chest organs, main vessels, and coronary bed in patients with CT-confirmed COVID-19 admitted to O.M. Filatov Municipal Clinical Hospital No. 15, Moscow for sudden chest pain, cough, and shortness of breath. Results. In CT of the chest organs, combinations of COVID-19 and pulmonary artery thromboembolism, central/peripheral lung cancer, and acute aortic syndrome manifestations were most common. Combinations of radiation techniques in pandemic settings are COVID-19 required by patients with the acute coronary syndrome. However, it will be possible to analyze all cases of a combination of acute chest pain and sudden shortness of breath in patients with COVID-19 only after processing an extensive array of data. Conclusion. In pandemic conditions, COVID-19 performing standard imaging methods should be not lost about the most frequent causes of chest pain and sudden shortness of breath, complementing native MSCT with contrasting enhancement in suspected pathology of the main arteries, and small circulation in high-risk patients.

scholarly journals Effect of a Triage‐Based Screening Protocol on Diagnosis and Treatment of Acute Coronary Syndrome in a Tanzanian Emergency Department: A Prospective Pre‐Post Study

2020 ◽  
Vol 9 (16) ◽  
Author(s):  
Julian T. Hertz ◽  
Francis M. Sakita ◽  
Godfrey L. Kweka ◽  
Gerald S. Bloomfield ◽  
John A. Bartlett ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Chest Pain ◽  
Troponin I ◽  
Point Of Care ◽  
Sub Saharan Africa ◽  
Shortness Of Breath ◽  
Coronary Syndrome ◽  
Screening Protocol ◽  
Sub Saharan ◽  
Research Assistants

Background Evidence suggests that acute coronary syndrome (ACS) is underdiagnosed in sub‐Saharan Africa. Triage‐based interventions have improved ACS diagnosis and management in high‐income settings but have not been evaluated in sub‐Saharan African emergency departments (EDs). Our objective was to estimate the effect of a triage‐based screening protocol on ACS diagnosis and care in a Tanzanian ED. Methods and Results All adults presenting to a Tanzanian ED with chest pain or shortness of breath were prospectively enrolled. Treatments and clinician‐documented diagnoses were observed and recorded. In the preintervention phase (August 2018 through January 2019), ACS testing and treatment were dictated by physician discretion, as per usual care. A triage‐based protocol was then introduced, and in the postintervention phase (January 2019 through October 2019), research assistants performed ECG and point‐of‐care troponin I testing on all patients with chest pain or shortness of breath upon ED arrival. Pre‐post analyses compared ACS care between phases. Of 1020 total participants (339 preintervention phase, 681 postintervention phase), mean (SD) age was 58.9 (19.4) years. Six (1.8%) preintervention participants were diagnosed with ACS, versus 83 (12.2%) postintervention participants (odds ratio [OR], 7.51; 95% CI, 3.52–19.7; P <0.001). Among all participants, 3 (0.9%) preintervention participants received aspirin, compared with 50 (7.3%) postintervention participants (OR, 8.45; 95% CI, 3.07–36.13; P <0.001). Conclusions Introduction of a triage‐based ACS screening protocol in a Tanzanian ED was associated with significant increases in ACS diagnoses and aspirin administration. Additional research is needed to determine the effect of ED‐based interventions on ACS care and clinical end points in sub‐Saharan Africa.

scholarly journals Pheochromocytoma presenting as a mimic of acute coronary syndrome

2016 ◽  
Vol 15 (3) ◽  
pp. 145-148
Author(s):  
Yasmin Hakim ◽  
◽  
Anna Forbes ◽  
Momina Khan ◽  
Benjamin C Whitelaw ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Chest Pain ◽  
Adrenal Mass ◽  
Troponin I ◽  
Clinical Presentation ◽  
Elevated Serum ◽  
Coronary Syndrome ◽  
Crisis Events ◽  
Common Clinical Presentation ◽  
Patient At Risk

Chest pain with elevated serum troponin is a common clinical presentation and is normally managed as suspected myocardial infarction or acute coronary syndrome (ACS). We report a 49 year old man who presented with central chest pain sweating and breathlessness. He had a significantly elevated serum troponin I level and a subsequent angiogram showed near normal coronary arteries. He was subsequently investigated for fever and found to have a 3cm right sided adrenal mass consistent with a pheochromocytoma. After confirmation and appropriate blockade laparoscopic adrenalectomy was performed. Pheochromocytoma may present as a mimic of acute coronary syndrome but this is often unrecognized and leaves the patient at risk of future pheo crisis events which may be fatal.

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