Moffat Alexander, Formisano Francesco, Routledge Helen, Bradbury Eleanor, Wilson David
Department of Cardiology, Worcestershire Acute Hospitals NHS Trust, Worcester, UK
Department of Cardiology, Worcestershire Acute Hospitals NHS Trust, Worcester, UK.
BMJ Case Rep. 2022 Apr 22;15(4):e242036. doi: 10.1136/bcr-2021-242036.
A woman in her 70s presented with chest pain, which was initially thought to be an acute coronary syndrome but subsequently felt to be pericarditis. Chest radiography and echocardiography demonstrated striking cardiomegaly and marked biatrial dilatation, likely secondary to undiagnosed restrictive cardiomyopathy. The patient remained well on the ward for some days with only mild discomfort and stable haemodynamics. CT of the thorax went on to unexpectedly demonstrate a Stanford type A aortic dissection. The patient was promptly transferred for emergent surgery but sadly died intraoperatively.Delayed or missed diagnosis of acute aortic dissection (AAD) is common. The dual-processing theory (DPT) of human judgement can be applied to medical decision making and used to explain this potential for diagnostic error in AAD diagnosis. A greater awareness of DPT and the role of heuristics and biases in medical decision making may help to reduce medical diagnostic error.
一名70多岁的女性因胸痛就诊,最初被认为是急性冠状动脉综合征,但随后诊断为心包炎。胸部X线和超声心动图显示显著的心脏扩大和明显的双房扩张,可能继发于未确诊的限制性心肌病。患者在病房里住了几天,只有轻微不适,血流动力学稳定。胸部CT意外显示为斯坦福A型主动脉夹层。患者被迅速转往急诊手术,但不幸在术中死亡。急性主动脉夹层(AAD)的诊断延迟或漏诊很常见。人类判断的双加工理论(DPT)可应用于医疗决策,并用于解释AAD诊断中这种潜在的诊断错误。对DPT以及启发式和偏差在医疗决策中的作用有更高的认识可能有助于减少医疗诊断错误。