SHM Converge Scientific Abstract ePoster Gallery-Don't Stop the Diagnostic Process, Because 'Winners Don't Quit and Quitters Don't Win'

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The document emphasizes that diagnosis is both a classification and an iterative clinical process. Accurate, timely diagnosis improves outcomes because it guides appropriate treatment. A case of a 90-year-old man with hypertension, coronary artery disease, and chronic lymphocytic lymphoma illustrates the challenges of diagnostic reasoning.<br /><br />He presented with worsening shortness of breath, orthopnea, cough, and leg swelling, along with hypoxia, tachypnea, hypotension, crackles, elevated JVP, edema, acute kidney injury, elevated lactate, high troponin, and markedly elevated NT-proBNP. Chest CT showed pulmonary edema, right upper lobe consolidation, and bilateral pleural effusions. He was initially treated for possible pneumonia/septic shock with antibiotics and a fluid bolus, which temporarily improved lactate but later worsened his respiratory and hemodynamic status, prompting ICU transfer. Cardiology advised pressors and avoiding further fluids due to high filling pressures, with later diuresis when possible. Despite this, the patient deteriorated, developed reduced ejection fraction and evidence of high filling pressures, and ultimately died after transition to comfort care.<br /><br />The central message is: do not stop the diagnostic process too early. Diagnosis should involve continuous information gathering, integration, interpretation, hypothesis updating, and communication among clinicians, patients, and families. Clinicians do not need absolute certainty before treating, but should use emerging data to reduce uncertainty and refine the working diagnosis.<br /><br />In this case, adjudicators judged diagnostic error as highly likely. The main faults were underweighting signs of volume overload, delayed recognition of mixed cardiogenic and distributive shock, and insufficient physiologic monitoring/reassessment of volume status. The case highlights how anchoring and incomplete reassessment can lead to harmful diagnostic error, especially in complex shock states.

Asset Subtitle

Abhishek Goyal

Meta Tag

Author List Abhishek Goyal, Jeffrey L. Schnipper, Mohammed Wazir

Category Clinical Vignettes

Concept Diagnostic Process

Concept Clinical Reasoning

Concept Volume Status

Concept Working Diagnosis

Concept Anchoring Bias

Distinguished Non-Finalist

Presenter Organization Brigham & Women's Hospital, Harvard Medical School

Presenting Author Abhishek Goyal

Track Adult

Keywords

diagnosis

clinical reasoning

diagnostic error

cardiogenic shock

septic shock

volume overload

heart failure

pulmonary edema

hypotension

reassessment

Diagnostic Process

Clinical Reasoning

Volume Status

Working Diagnosis

Anchoring Bias