Improving Diagnosis meeting

Case nº 1

Background

• Patient age: 75 years old

• Previous diagnosis: Chronic Obstructive Lung Disease. Poliglobulia. Diabetes. Hypertension.

• No allergies.

• Medications: Aspirin, Digoxin, Metformine, antihypertensive drugs.

Clinical presentation

• The patient went to the emergency department for an increase in dyspnea, cough and sputum.

• He was admitted with the initial diagnosis of respiratory infection without consolidation, starting antibiotics (levofloxacin) after cultures samples. Subcutaneous profilactic heparin was also started.

Diagnostic assessments

• Physical examination: mild swollen ankles.

• Laboratory examination:ECG atrial fibrillation. Protrombin:86%. Normal kidney function.

• He started treatment with corticoids, antibiotics, prophylactic heparin, IECA.

• His general and respiratory condition improved during the first day.

Evolution (I): Clinical Problem

• Three days after admission, during the night, he started with strong pain around the right inguinal area, worsening with mobilization of the leg. He still referred shortness of breath occasionally.

• Oral anticoagulation was started.

• Clinical Examination: strong pain at the palpation around right iliaca fossa.

• Clinical diagnosis: 1). Pulmonary embolism 2). Pain over the right iliaca area.

Laboratory and Radiological Evaluation at that moment

• Blood Test: HB: 14,7. Hto: 45. P: 117.000

• Coagulation: Protrombin: 90%.

• APTTsec: 19,2(25-35) APTT:0,7(0,8-1,19)

• X-Ray right hip and femur: normal

Evolution (II)

• Pain at the right iliaca fossa improved during the next morning. During the nigth of the next day the patient deteriorates with pain on his right leg and dyspnea. In a few hours his blood pressure dropped and intravenous fluid was started. A new examination showed a bruise at the inguinal area.

• After a sonogram and a TAC scan a diagnosis of Retroperitoneal hematoma was stablished.A cyst at the right kidney was also observed.

Analysis:Cognitive Bias

• Basically was a wrong clinical reasoning process based in the normal hemoglobin levels: normal values makes difficult thinking about bleeding.

• Most of the evaluation were made during the night with a lot of paper work, suggesting also a compound of fatigue and bad communication.

Analysis: System aspects

• Lack of communications between differents attending physicians.

• Non organized medical record

• Lack of alerts about strong changes in laboratory values (hemoglobin levels evolution).

Hemoglobin levels evolution

Date 10/6*

11/6 13/6 14/6**

16/6***

Hb 17,8 16,8 18,7 14,7 10,5

*Hospital Admission ** pain started ***Diagnosis

Final Comments(I)

• This patients previously diagnosed with chronic pulmonary disease presents with retroperitoneal hematoma during his stay at the hospital. One possible risk factor could be treatment with prophylactic heparin what is very unusual. Another possibility could be bleeding from the cyst at the right kidney.

Final Comments (II)

• Appart of the cognitive aspects involved in this case, is clear that an improvement at the system level (Electronic Health Information System) could help to diagnosis the bleeding, showing the results in a flow-chart .Even at the moment of the bleeding, hemoglobin levels were under normal range, but this conclusion was wrong due to the high initial hemoglobin values related to previous diagnosis of Poliglobulia .