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