Heuristic Errors in Medicine: The Patient with a Red Eye

2. Heuristic Errors in Medicine:The Patient with a Red Eye Richard K. Reed, M.D., F.A.C.P.

3. History • CC: Problem with right eye • PI: RJ is a 40 yo female with Downs Syndrome with itching of the right eye for 3 days. She had associated pain in the eye. Her caregiver could not restrain her from rubbing the eye. There was no known history of trauma to the eye. She had no recent URI symptoms.

4. PMH • Downs Syndrome – functions as 3 yo • Leukemia as a child • Stroke as result of complication of chemotherapy for leukemia • Obesity • Hypertension • Hyperlipidemia • Primary hypothyroidism • Sleep apnea

5. Social History • Medications: - HCTZ 25 mg. daily - Lisinopril 10 mg. daily - Levothyroxime 100 mcg. daily - Lovastatin 40 mg. daily - Citalopram 20 mg. daily - D3 2000 units daily - B12 1000 mcg daily • NKA • No alcohol, tobacco, or other drug abuse • Needs help with most ADLs

6. Family History • Father – died recently of complications of diabetes, renovascular hypertension, chronic renal disease, ischemic heart disease • Mother – died in 1980s of metastatic breast cancer • Aunt – died recently of complications of diabetes and heart failure

7. ROS • No recent URI symptoms • No headache • No fever • No known head or eye trauma • No known abuse issues

8. Physical Examination • BP 130/80 • Pulse 64 • RR 16 • Temp 97.4 • Weight 170# • Height 4’7” • BMI 39.5 kg/m2 • No known narcotic or elicit drug use • No tobacco use

9. Physical Examination cont. • Gen – obese, Downs phenotype, constantly rubbing her right eye • HEENT -visual acuity – not able to access -examiner difficulty on observing right eye -right eye red with conjunctival suffusion -brief look at cornea- no problem -fundus exam impossible -fluorescein staining – NA -slit lamp exam - NA

10. Physical Examination cont. • Neck – short • Chest – clear • Heart – RRR with no murmur • Abdomen – obese, no organomegaly • Extremities – mild pretibial edema • Neuro – wheelchair bound; residual neurologic sequelae of mild left hemiparesis

11. Assessment • Right red eye – conjunctivitis, iritis or corneal abrasion • Downs Syndrome • Obesity

12. Plan • Unsure of correct diagnosis, I referred her to an ophthalmologist.

13. Clinical Course • Ophthalmologist 1. He did eye exam the following morning and prescribed eye drops. 2. She returned to see him in 4 days. a. Ophthalmologist was apparently unable to adequate exam. b. With suspicion for underlying pathology, he took her to surgery for exam under anesthesia and found a corneal perforation. c. Evisceration (not enucleation) procedure was performed. d. Prosthetic ball was placed into scleral husk

14. Later Clinical Course • Patient would not leave eye guard in place. • The ophthalmologist subsequently removed the ball from the scleral husk. • The scleral husk was left in place and will atrophy.

15. Question Any ideas as to what was the underlying problem with this patient’s eye?

16. Diagnosis • Keratoconus • Corneal hydrops • Corneal perforation

17. Keratoconus

18. Munson’s Sign

19. Corneal hydrops

20. Pathology • Downs Syndrome - - - keratoconus • Keratoconus - - - corneal hydrops • Corneal hydrops - - - corneal perforation

21. What went wrong? • My lack of knowledge • Ophthalmology consultation timing • Ophthalmology • Patient factors

22. Cognitive Illusions • The hot road illusion • The retrospectroscope: Hindsight is always 20/20 vision. • “You can see more by looking.” - Yogi Berra

23. Diagnostic Errors with Clinical Heuristics • Availability heuristic errors • Anchoring errors • Framing errors • Blind obedience • Premature closure • Faulty or inadequate knowledge

24. Back to the Patient with the Red Eye • Availability heuristic errors • Anchoring errors • Framing errors • Blind obedience • Premature closure • Faulty or inadequate knowledge

25. The Swiss Cheese Analogy • Systems related errors • Cognitive errors

26. The Doctor, by Sir Luke Fildes

27. Words of Wisdom • There is nothing more humbling than the practice of medicine. • Continuing Medical Education

28. Bibliography • googleimages.com IMB3641 65 low jpg (picture of corneal hydrops) • googleimages.com CLS0610 (picture of Munson’s sign) • Graber ML, Franklin N, Gordon R. Diagnostic Error in Internal Medicine. Arch Intern Med. 2005;165(13):1493-1499. [PMID:16009864].   • Grewal S, Laibson PR, Cohen EJ. Acute hydrops in the corneal ectasias: associated factors and outcomes. Trans AM Ophthalmology Society 1997; 97:187-203. • Groopman J. How Doctors Think. 2008. Houghton Mifflin • http://www.cornea.org (picture of keratoconus) • MKSAP 15, American College of Physicians • Redelmeier DA. Improving patient care. The cognitive psychology of missed diagnoses. Ann Intern Med. 2005;142(2):115-120. [PMID:15657159].   • Rothschild JM, Landrigan CP, Cronin JW, et al. The Critical Care Safety Study: The incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med. 2005;33(8):1694-1700. [PMID:16096443].   • Tuft SJ, Gregory, Wm, Buckley RJ. Acute corneal hydrops. Ophthalmology: Oct. 1994:1738-44. • Vidyarthi A, Arora V, Schnipper J, Wall S, Wachter R. Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. J Hosp Med. 2006;1(4):257-266. [PMID:17219508].