1.  Oncology records:
 Surgery october 2006: bilateral ovarian
CLINICAL CASE endometrioid carcinoma, stage IIIC, treated
with optimal debulking and adjuvant CT.
 Dissemination to the lungs, mediastinal
Woman, 65 años. nodes, and peritoneum, 6 months after
finishing CT. Several chemotherapy lines
Allergies: penicillin
until July 2012. Intestinal suboclusion
Asthma resolved in a conservative way in May-April
2012.
Mitral valve prolapse
 *

2. CLINICAL CASE
PRESENT DISEASE
- Nausea and vomiting for three days, with “dark vomit” suggesting bleeding. Low fever and
cough.
- Constipation
EGEndoscopy: péptic esophagitis grade C (Los Angeles). No tumor visible in
stomach or duodenum
Treatment:
Treatment:
pantoprazol
pantoprazol
Ondasetron IV
Ondasetron IV
Diet and hydratation
Diet and hydratation

3. EVOLUTION:
48 hours later: fever 38.5 ºC .
Cough and mucosal sputum and no other signs of sepsis..
Laboratory:
WC: L 3300 (N 2130, L 480), Hb 8.6, plat 81000. Normal coagulation. BQ: glu 293, Cr 0.53, proteins
5.1, GOT normal, GPT 47, GGT 156, LDH 292, albumina 1.9, prealbumina 8.2
Blood cultures : negatives
Rx tórax
Levofloxacino
i.v 500 mg/ d
* 96h later 
oral liquids.
31/07/12 31/07/12

4. EVOLUTION:
Progressive clinical deterioration  increase in dyspnea, cough and “dark” mucosal sputum .
:
Urine antigens  negative for Legionella and pneumococo
Sputum culture  mixed bacteria, possible contamination
Blood cultures  negatives
XR Thorax:
Laboratory WBC normal, anemia grade I, trombopenia grade II, severe desnutrition.

5. Radiological evolution
06/08/12 06/08/12

6. Radiological evolution
09/08/12 06/08/12

7.  Treatment:
Differential Diagnosis: : aerosolterapia, acetilcisteina,
corticoids, oxigen
1. Pneumonía adcquired in the community
in a immunocompromised patient.
 We introduced a new antibiotic
2. Atypical pneumonia
ceftriaxona 2 gr/24h i.v
3. Tumoral progression.
4. Pulmonary drug toxicity We changed levofloxacino +
ceftriaxona  Imipenem 1 gr/8h
iv
* Because of Oral candidiasis:
Fluconazol 200 mg/12h iv

8. TC thórax 13/08/12
Esophagi
cal
dilatation

9. IMPROVING DIAGNOSIS AND CLINICAL REASONING:
Confirmación bias
2. COGNITIVE COMPOUND
1. PROBLEM CLASSIFICATION
We think that our diagnosis was initially wrong
A) Diagnósis never made
because of the assumption of a “normal”
B) Wrong Diagnosis: even thinking pneumonia to explain the symptoms of the
that a pulmonary infection was deteriorating patient. In a retrospective way we noticed that
the situation of the patient, the main problem cough and dyspnea were clearly associated to food
was the aspiration of food from the
aesophagical area to the lungs, without a clear ingestion.
explanation.
This clinical situation can be defined as a
C) Diagnosis delay
Confirmation Bias..
How to improve? When our model doesn,t fit for the main signs,
symptoms and evolution, we have to think in another alternative

10. IMPROVING DIAGNOSIS AND CLINICAL REASONING:
Confirmación bias
2. COGNITIVE COMPOUND
1. PROBLEM CLASSIFICATION
We think that our diagnosis was initially wrong
A) Diagnósis never made
because of the assumption of a “normal”
B) Wrong Diagnosis: even thinking pneumonia to explain the symptoms of the
that a pulmonary infection was deteriorating patient. In a retrospective way we noticed that
the situation of the patient, the main problem cough and dyspnea were clearly associated to food
was the aspiration of food from the
aesophagical area to the lungs, without a clear ingestion.
explanation.
This clinical situation can be defined as a
C) Diagnosis delay
Confirmation Bias..
How to improve? When our model doesn,t fit for the main signs,
symptoms and evolution, we have to think in another alternative