1. Improving Diagnosis meeting
Case nº 1

2. Background
• Patient age: 75 years old
• Previous diagnosis: Chronic Obstructive
Lung Disease. Poliglobulia. Diabetes.
Hypertension.
• No allergies.
• Medications: Aspirin, Digoxin, Metformine,
antihypertensive drugs.

3. Clinical presentation
• The patient went to the emergency department
for an increase in dyspnea, cough and sputum.
• He was admitted with the initial diagnosis of
respiratory infection without consolidation,
starting antibiotics (levofloxacin) after cultures
samples. Subcutaneous profilactic heparin was
also started.

4. Diagnostic assessments
• Physical examination: mild swollen
ankles.
• Laboratory examination:ECG atrial
fibrillation. Protrombin:86%. Normal kidney
function.
• He started treatment with corticoids,
antibiotics, prophylactic heparin, IECA.
• His general and respiratory condition
improved during the first day.

5. Evolution (I): Clinical Problem
• Three days after admission, during the night, he
started with strong pain around the right inguinal
area, worsening with mobilization of the leg. He
still referred shortness of breath occasionally.
• Oral anticoagulation was started.
• Clinical Examination: strong pain at the palpation
around right iliaca fossa.
• Clinical diagnosis: 1). Pulmonary embolism 2).
Pain over the right iliaca area.

6. Laboratory and Radiological Evaluation at that
moment
• Blood Test: HB: 14,7. Hto: 45. P: 117.000
• Coagulation: Protrombin: 90%.
• APTTsec: 19,2(25-35) APTT:0,7(0,8-1,19)
• X-Ray right hip and femur: normal

7. Evolution (II)
• Pain at the right iliaca fossa improved during the
next morning. During the nigth of the next day
the patient deteriorates with pain on his right leg
and dyspnea. In a few hours his blood pressure
dropped and intravenous fluid was started. A
new examination showed a bruise at the inguinal
area.
• After a sonogram and a TAC scan a diagnosis
of Retroperitoneal hematoma was stablished.A
cyst at the right kidney was also observed.

8. Analysis:
Cognitive Bias
• Basically was a wrong clinical reasoning
process based in the normal hemoglobin
levels: normal values makes difficult
thinking about bleeding.
• Most of the evaluation were made during
the night with a lot of paper work,
suggesting also a compound of fatigue
and bad communication.

9. Analysis: System aspects
• Lack of communications between
differents attending physicians.
• Non organized medical record
• Lack of alerts about strong changes in
laboratory values (hemoglobin levels
evolution).

10. Hemoglobin levels evolution
Date 10/6 11/6 13/6 14/6 16/6
* ** ***
Hb 17,8 16,8 18,7 14,7 10,5
*Hospital Admission ** pain started ***Diagnosis

11. Final Comments(I)
• This patients previously diagnosed with
chronic pulmonary disease presents with
retroperitoneal hematoma during his stay
at the hospital. One possible risk factor
could be treatment with prophylactic
heparin what is very unusual. Another
possibility could be bleeding from the cyst
at the right kidney.

12. Final Comments (II)
• Appart of the cognitive aspects involved in this
case, is clear that an improvement at the
system level (Electronic Health Information
System) could help to diagnosis the bleeding,
showing the results in a flow-chart .Even at the
moment of the bleeding, hemoglobin levels were
under normal range, but this conclusion was
wrong due to the high initial hemoglobin values
related to previous diagnosis of Poliglobulia .