Confirmation bias and pneumonia
-
Upload
lorenzo-alonso -
Category
Health & Medicine
-
view
121 -
download
0
Transcript of Confirmation bias and pneumonia
CLINICAL CASE
Oncology records:
Surgery october 2006: bilateral ovarian endometrioid carcinoma, stage IIIC, treated with optimal debulking and adjuvant CT.
Dissemination to the lungs, mediastinal nodes, and peritoneum, 6 months after finishing CT. Several chemotherapy lines until July 2012. Intestinal suboclusion resolved in a conservative way in May-April 2012.
*
Woman, 65 años.
Allergies: penicillin
Asthma
Mitral valve prolapse
PRESENT DISEASE
- Nausea and vomiting for three days, with “dark vomit” suggesting bleeding. Low fever and
cough.
- Constipation
CLINICAL CASE
EGEndoscopy: péptic esophagitis grade C (Los Angeles). No tumor visible in
stomach or duodenum
Treatment:
pantoprazol
Ondasetron IV
Diet and hydratation
Treatment:
pantoprazol
Ondasetron IV
Diet and hydratation
EVOLUTION:
48 hours later: fever 38.5 ºC .
Cough and mucosal sputum and no other signs of sepsis..
Laboratory:
WC: L 3300 (N 2130, L 480), Hb 8.6, plat 81000. Normal coagulation. BQ: glu 293, Cr 0.53, proteins
5.1, GOT normal, GPT 47, GGT 156, LDH 292, albumina 1.9, prealbumina 8.2
Blood cultures : negatives
Rx tórax
Levofloxacino
i.v 500 mg/ d
* 96h later
oral liquids.
31/07/12 31/07/12
EVOLUTION:
Progressive clinical deterioration increase in dyspnea, cough and “dark” mucosal sputum .
:
Urine antigens negative for Legionella and pneumococo
Sputum culture mixed bacteria, possible contamination
Blood cultures negatives
XR Thorax:
Laboratory WBC normal, anemia grade I, trombopenia grade II, severe desnutrition.
Radiological evolution
06/08/12 06/08/12
Radiological evolution
09/08/12 06/08/12
Differential Diagnosis:
Treatment:
: aerosolterapia, acetilcisteina,
corticoids, oxigen
We introduced a new antibiotic
ceftriaxona 2 gr/24h i.v
We changed levofloxacino + ceftriaxona
Imipenem 1 gr/8h iv
* Because of Oral candidiasis:
Fluconazol 200 mg/12h iv
1. Pneumonía adcquired in the community
in a immunocompromised patient.
2. Atypical pneumonia
3. Tumoral progression.
4. Pulmonary drug toxicity
TC thórax 13/08/12
Esophagical dilatation
1. PROBLEM CLASSIFICATION
A) Diagnósis never made
B) Wrong Diagnosis: even thinking that a pulmonary infection was deteriorating the situation of the patient, the main problem was the aspiration of food from the aesophagical area to the lungs, without a clear explanation.
C) Diagnosis delay
IMPROVING DIAGNOSIS AND CLINICAL REASONING: Confirmación bias
2. COGNITIVE COMPOUND
We think that our diagnosis was initially wrong
because of the assumption of a “normal”
pneumonia to explain the symptoms of the patient.
In a retrospective way we noticed that cough and
dyspnea were clearly associated to food ingestion.
This clinical situation can be defined as a
Confirmation Bias..
How to improve? When our model doesn,t fit for the main signs, symptoms and evolution, we have to think in another alternative