Walker McCall, Warburton Karen M, Rencic Joseph, Parsons Andrew S
University of Virginia, Department of Medicine, Charlottesville, USA.
Tufts Medical Center, Department of Medicine, Boston, MA, USA.
Diagnosis (Berl). 2019 Nov 26;6(4):387-392. doi: 10.1515/dx-2019-0030.
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.
背景 人类认知缺陷通常会导致临床推理失误，进而引发诊断错误。对哪些临床发现符合和/或不符合可能的及“不容错过”的诊断进行元认知结构化反思，可能会减少此类错误。 病例介绍 一名57岁男性从诊所被送往急诊科，伴有胸痛、严重呼吸急促、虚弱和冷汗。进一步检查发现其存在多种冠状动脉疾病风险因素、运动性呼吸困难突然发作、休息后胸痛未完全缓解、轻度心动过速和缺氧、心电图（ECG）异常、血清心脏生物标志物升高以及在无左侧心力衰竭情况下B型利钠肽（BNP）升高。他接受了急性冠状动脉综合征（ACS）治疗，出院后很快因症状恶化再次就诊，最终被诊断为次大面积肺栓塞（PE）。 结论 通过对两家机构临床推理专家的诊断推理过程进行综合评论，本病例强调了频繁评估匹配度以及明确解释不一致特征的重要性，以避免过早下结论和诊断错误。提供了一个鱼骨图以直观展示导致诊断错误的主要因素。一名病例讨论者描述了诊断模式作为一种分析推理策略的重要性，有助于创建鉴别诊断、问题呈现以总结最新发现、采用波普尔分析方法试图证伪可能性较小的假设，以及将相关的阳性和阴性结果与先前学到的疾病脚本进行匹配。最后，本病例除了提供一个关于过早下结论的陷阱、误区和要点外，还提供了临床教学要点。
