Learning objectives: Attendings should listen to trainees carefully. Physicians should not completely accept diagnoses that other physicans make. Physicians should not assume that the laboratory and radiology findings will be normal before checking on the results.
Case information: A 2 month old male with history of an UTI presented to the emergency room with emesis, cloudy urine and concerns of increasing fussiness and poor feeding. He was noted to have poor weight gain and was admitted to the hospital with the diagnoses of failure to thrive and recurrent urinary tract infection. On exam, the medical student reported that the baby was well appearing but with a grade II/VI systolic blowing murmur at the left sternal border. He mentioned this to the attending who did not confirm the murmur as she focused on how well appearing the baby was and that the diagnosis was a “urinary tract infection.” Urinalysis and urine culture were negative. A renal ultrasound was normal and VCUG showed bilateral grade III reflux and, incidentally, cardiomegaly. These results were noted that day by the medical student. The next day, the baby was clammy, diaphoretic and had intermittent perioral cyanosis. The VCUG results were then reviewed by a different attending. A cardiology consult was called and a stat echocardiogram demonstrated TAPVR draining to the coronary sinus and severe right heart dilation. He was transferred to the CVICU for surgical repair.
Discussion: This case illustrates a number of cognitive errors in diagnosis. The attending accepted the ER diagnosis (premature closure) and despite evidence of a heart murmur, the attending demonstrated “confirmation bias” by not carefully listening to the patient’s murmur. The student demonstrated “blind obedience” in that he noted the heart murmur but did not share the finding with other physicians as the attending was so senior to him.
See more of: The 33rd Annual Meeting of the Society for Medical Decision Making