PTSD: Post-Traumatic Stroke DisorderPTSD: Post-Traumatic Stroke DisorderPTSD: Post-Traumatic Stroke DisorderPTSD: Post-Traumatic Stroke DisorderJoshua McKay MD and Ryan Kraemer MD

University of Alabama at BirminghamJoshua McKay MD and Ryan Kraemer MD

University of Alabama at Birmingham

Learning Objectives 

References

Patient Presentation

Take Home Points

Evaluation and Diagnosis

1. Recognize a medical condition that can mimic panic attacks

2. Recognize common cognitive errors that may lead to delay in diagnosis and increased morbidity and/or mortality

   

54 yo AAF with post traumatic stress disorder secondary to a MVA presented to her psychiatrist with new onset intermittent severe headaches associated with nervousness and tachypnea

Diagnosed with panic attacks and treated

Four Months Later

Presents to her PCP with similar symptoms

Treated for previously diagnosed panic attacks

One Year After Onset of Symptoms

Presents to emergency department complaining of acute onset of left-sided weakness

Vital signs, including BP 115/48, within normal limits

MRI confirms ischemic stroke

Additional work-up unrevealing

Treated appropriately for stroke

Symptoms of a pheochromocytoma can mimic those of a panic attack

Cognitive errors can lead to substantial morbidity and/or mortality

An increased awareness of cognitive errors can help physicians avoid these pitfalls in diagnosis.

Diagnostic ErrorsHospital Course Continued to experience her original symptoms

Treated as previously diagnosed panic attacks During one of these episodes she developed a severe

generalized headache Repeat head CT showed hemorrhagic conversion of

the ischemic lesion BP was 234/140 No history or prior documentation of hypertension

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4. Graber M, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med 2005;165:1493-1499.

5. Kostopoulou O, Delaney BC, Munro CW. Diagnostic difficulty and error in primary care - a systematic review. Fam Pract 2008;25(6):400-13.

6. Redman JC, Peloso OA, Milne RL, Kaminsky NI, Ellis SC, Wolfel DA, Martinez PU. Asymptomatic pheochromocytoma. Diagnosis after hemorrhagic stroke in a middle-aged patient. Postgrad Med 1983;73(4):279,282-5.

Laboratory Data:

Diagnosis:

Pheochromocytoma

Following surgical resection the patient had complete resolution of symptoms

Leading cause of medical malpractice claim

Second leading cause of preventable adverse events

Account for an estimated 40,000-80,000 deaths per year

Cognitive errors are the most common cause of misdiagnosis

Presentation Characteristics Presentation characteristics commonly

associated with cognitive errors: Atypical presentation

Non-specific complaints

Low prevalence of disease

Presence of co-morbiditiesCognitive Errors

Common cognitive errors illustrated in this case: Premature Closure

Failure to consider reasonable alternatives after an initial diagnosis is reachedLikely played a role in the initial diagnostic process

AnchoringLocking onto a salient feature early in the diagnostic process and then failing to adjust this process when new information is obtainedWith a diagnosis of PTSD, it was easy to anchor to the complaint of nervousness while ignoring features not consistent with panic attacks

Diagnostic MomentumFailure to consider other diagnoses after a diagnosis has been attached to a patientLed to continued treatment for panic attacks and further delayed the proper diagnosis

CT-Abd/Pelvis revealed a 10 cm complex right adrenal mass