Transcript Poster 2 - University of Alabama at Birmingham

PTSD: Post-Traumatic Stroke Disorder
Joshua McKay MD and Ryan Kraemer MD
University of Alabama at Birmingham
Learning Objectives
1. Recognize a medical condition that can mimic
panic attacks
2. Recognize common cognitive errors that may
lead to delay in diagnosis and increased
morbidity and/or mortality
Patient Presentation
 54 yo AAF with post traumatic stress disorder
secondary to a MVA presented to her
psychiatrist with new onset intermittent severe
headaches associated with nervousness and
tachypnea
 Diagnosed with panic attacks and treated
Hospital Course
Diagnostic Errors
 Continued to experience her original symptoms
 Treated as previously diagnosed panic attacks
 During one of these episodes she developed a severe
generalized headache
 Repeat head CT showed hemorrhagic conversion of
the ischemic lesion
 BP was 234/140
 No history or prior documentation of hypertension
Evaluation and Diagnosis
 Laboratory Data:
Serum
(nmol/L)
24 hour Urine
(mcg/24 hrs)
Metanephrines
7.7
(nl <0.5)
7310
(nl 90-315)
Normetanephrines
146
(nl <0.9)
115,291
(nl 122-676)
Four Months Later
One Year After Onset of Symptoms
 Presents to emergency department complaining
of acute onset of left-sided weakness
 Vital signs, including BP 115/48, within
normal limits
 MRI confirms ischemic stroke
 Additional work-up unrevealing
 Treated appropriately for stroke
 Second leading cause of preventable adverse events
 Diagnosis:
Pheochromocytoma
Following surgical
resection the patient had
complete resolution of
symptoms
CT-Abd/Pelvis revealed a 10 cm
complex right adrenal mass
 Presentation characteristics commonly
associated with cognitive errors:
 Atypical presentation
 Account for an estimated 40,000-80,000 deaths per year
 Non-specific complaints
 Cognitive errors are the most common cause of misdiagnosis
 Low prevalence of disease
Cognitive Errors
 Common cognitive errors illustrated in this case:
 Premature Closure
Failure to consider reasonable alternatives after an
initial diagnosis is reached
Likely played a role in the initial diagnostic process
 Anchoring
Locking onto a salient feature early in the diagnostic
process and then failing to adjust this process when new
information is obtained
With a diagnosis of PTSD, it was easy to anchor to the
complaint of nervousness while ignoring features not
consistent with panic attacks
 Presents to her PCP with similar symptoms
 Treated for previously diagnosed panic
attacks
 Leading cause of medical malpractice claim
Presentation Characteristics
 Diagnostic Momentum
Failure to consider other diagnoses after a diagnosis
has been attached to a patient
Led to continued treatment for panic attacks and further
delayed the proper diagnosis
 Presence of co-morbidities
Take Home Points
 Symptoms of a pheochromocytoma can
mimic those of a panic attack
 Cognitive errors can lead to substantial
morbidity and/or mortality
 An increased awareness of cognitive errors
can help physicians avoid these pitfalls in
diagnosis.
References
1. Chandra A, Nundy S, Seabury SA. The Growth of Physician Medical Malpractice
Payments: Evidence from the National Practitioner Data Bank. Health Aff 2005;W5240-9.
2. Leape LL, Brennan TA, Laird N, et al. The Nature of Adverse Events in Hospitalized
Patients-Results of the Harvard Medical Practice Study II. N Engl J Med 1991;324:37784.
3. Leape LL, Berwick DM, Bates DW. Counting deaths due to medical errors. JAMA
2002;288(19):2405.
4. Graber M, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med
2005;165:1493-1499.
5. Kostopoulou O, Delaney BC, Munro CW. Diagnostic difficulty and error in primary care - a
systematic review. Fam Pract 2008;25(6):400-13.
6. Redman JC, Peloso OA, Milne RL, Kaminsky NI, Ellis SC, Wolfel DA, Martinez PU.
Asymptomatic pheochromocytoma. Diagnosis after hemorrhagic stroke in a middle-aged
patient. Postgrad Med 1983;73(4):279,282-5.