Lessons in clinical reasoning ‒ pitfalls, myths, and pearls: a case of confusion, disequilibrium, and “picking at the air”
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Charles D. Magee
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Alexander S. Millard
Abstract
Objectives
Defects in human cognition commonly result in clinical reasoning failures that can lead to diagnostic errors.
Case presentation
A 43-year-old female was brought to the emergency department with 4–5 days of confusion, disequilibrium resulting in several falls, and hallucinations. Further investigation revealed tachycardia, diaphoresis, mydriatic pupils, incomprehensible speech and she was seen picking at the air. Given multiple recent medication changes, there was initial concern for serotonin syndrome vs. an anticholinergic toxidrome. She then developed a fever, marked leukocytosis, and worsening encephalopathy. She underwent lumbar puncture and aspiration of an identified left ankle effusion. Methicillin sensitive staph aureus (MSSA) grew from blood, joint, and cerebrospinal fluid cultures within 18 h. She improved with antibiotics and incision, drainage, and washout of her ankle by orthopedic surgery.
Conclusions
Through integrated commentary on the diagnostic reasoning process from clinical reasoning experts, this case underscores how multiple cognitive biases can cascade sequentially, skewing clinical reasoning toward erroneous conclusions and driving potentially inappropriate testing and treatment. A fishbone diagram is provided to visually demonstrate the major factors that contributed to the diagnostic error. A case discussant describes the importance of structured reflection, a tool to promote metacognitive analysis, and the application of knowledge organization tools such as illness scripts to navigate these cognitive biases.
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Research funding: None declared.
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Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
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Competing interests: Authors state no conflict of interest.
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Informed consent: Not applicable.
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Ethical approval: Not applicable.
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© 2021 Walter de Gruyter GmbH, Berlin/Boston
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Articles in the same Issue
- Frontmatter
- Editorial
- From Camille Nούς to Apollonian and the Dionysian scientists
- Review
- The role of D-dimer in periprosthetic joint infection: a systematic review and meta-analysis
- Mini Reviews
- Updated picture of SARS-CoV-2 variants and mutations
- Systematic review and cumulative meta-analysis of the diagnostic accuracy of glial fibrillary acidic protein vs. S100 calcium binding protein B as blood biomarkers in observational studies of patients with mild or moderate acute traumatic brain injury
- Opinion Papers
- The 6C model for accurately capturing the patient’s medical history
- Webside manner: maskless communication
- Original Articles
- Ways that nurse practitioner students self-explain during diagnostic reasoning
- Diagnostic reasoning: relationships among expertise, accuracy, and ways that nurse practitioner students self-explain
- Perspectives on the current state of pre-clerkship clinical reasoning instruction in United States medical schools: a survey of clinical skills course directors
- Use of a structured approach and virtual simulation practice to improve diagnostic reasoning
- Analyzing diagnostic errors in the acute setting: a process-driven approach
- Morning report goes virtual: learner experiences in a virtual, case-based diagnostic reasoning conference
- Stroke hospitalization after misdiagnosis of “benign dizziness” is lower in specialty care than general practice: a population-based cohort analysis of missed stroke using SPADE methods
- Discrepancy between emergency department admission diagnosis and hospital discharge diagnosis and its impact on length of stay, up-triage to the intensive care unit, and mortality
- Automated capture-based NGS workflow: one thousand patients experience in a clinical routine framework
- Short Communication
- Characterizing the relationship between diagnostic intensity and quality of care
- Case Reports – Lessons in Clinical Reasoning
- Lessons in clinical reasoning ‒ pitfalls, myths, and pearls: a case of confusion, disequilibrium, and “picking at the air”
- Hickam’s dictum, Occam’s razor, and Crabtree’s bludgeon: a case of renal failure and a clavicular mass
- Letters to the Editor
- Three learning concepts to improve diagnosis and enhance the practice of medicine
- Distributed cognition: a framework for conceptualizing telediagnosis in teams
- Performance of Fujirebio Espline SARS-CoV-2 rapid antigen test for identifying potentially infectious individuals
