Learning objectives: How to breach gap between clinical intuition and analytic clinical reasoning?
Case information: A 57-year old man presented to the emergency department complaining of frequent and painful urination over the past 3 days. Since urinalysis was negative for white blood cells, red blood cells, and leukocyte esterase. A Foley catheter was inserted and Terazosin 2 mg orally was started for BPH. Over the next 2 weeks the patient calls his primary care physician on several occasions with no improvement in symptoms. Terazosin was gradually increased to 10 mg and multiple pain medications were prescribed including Ketorolac by intramuscular injections. Two weeks after initial symptoms he patient was eventually diagnosed with Prostate abscess and admitted to hospital. Soon after admission the patient died from massive upper GI bleeding from Gastric ulcer. NSAIDs use for pain and antiplatelet activity of ASA and fluoxetine contributed to his demise
Discussion: This case illustrates how defects in cognitive processes lead to diagnostic errors. Nonspecific patient symptoms and a negative initial urinalysis were misinterpreted as absence of infection. Subtle cues indicating possible urinary retention were elevated to a high level (framing effect). Intuitive reasoning was applied in the diagnostic process. Incomplete data collection and “tunnel vision” reasoning towards BPH led to premature closure. Subsequent physicians (primary care physician and urologist) adopted the emergency department physician’s diagnosis (blind obedience).
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